Performing Oral Hygiene for an Unconscious Patient

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When preparing to provide a comatose patient with oral care, the nurse best ensures patient safety by first:

1. Assessing the patient's gag reflex.
2. Inspecting the patient's oral cavity.
3. Placing the bed into a flat position.
4. Providing appropriate suction equipment.

1. Assessing the patient's gag reflex.

Which of the following statements made by the nurse will be most effective in instructing ancillary staff assigned the task of providing oral care for an unconscious patient in order to maximize the staff's ability to safely provide the care?

1. "What are you prepared to do if the patient starts gagging?"
2. "Remember to use a gloved hand when assessing for a gag reflex."
3. "Do you understand the importance of evaluating the ability to swallow?"
4. "Be sure to check that your suction equipment is working effectively."

4. "Be sure to check that your suction equipment is working effectively."

Which of the following actions should have priority in order to best ensure that the
unconscious patient has the benefits of proper oral care?

1. Assessing the patient's lips and oral cavity for ulcerations, bleeding, dryness, or crusting
2. Documenting the patient's mucous membranes as moist and pink with no signs of inflammation
3. Arranging for an in-service of ancillary staff to ensure that effective care is being
provided
4. Interviewing the patient's family to assess their ability to provide appropriate oral
hygiene upon discharge

1. Assessing the patient's lips and oral cavity for ulcerations, bleeding, dryness, or crusting

Which of the following statements made by ancillary staff assigned with the responsibility of providing a comatose patient with oral hygiene reflects the best understanding of the
importance of appropriately communicating with the nurse regarding this current intervention?

1. "The state of her oral health has really improved since we started using the sponges."
2. "He did require some oral suctioning; I don't believe he has much of a gag reflex left."
3. "The family is concerned about being able to perform oral hygiene well once he is
discharged."
4. "The patient did not have any signs of inflammation or even dryness of his mucous
membranes."

2. "He did require some oral suctioning; I don't believe he has much of a gag reflex left."

5. Which of the following patients should be scheduled for oral care at least every 2 hours in order to best minimize the risk of dried oral mucous membranes?

1. 66-year-old patient with a history of petit mal seizures
2. 76-year-old hospice patient currently experiencing dyspnea
3. 85-year-old patient diagnosed with advanced Alzheimer disease
4. 47-year-old patient recently diagnosed with an oral cancerous lesion

2. 76-year-old hospice patient currently experiencing dyspnea

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