Oral Care Case Study and Quiz ATI
A nurse is assessing a client who is receiving chemotherapy and reports pain and burning in his mouth. The nurse notes red and inflamed oral mucosa. Which of the following finds should the nurse document? A. Stomatitis B. Halitosis C. Gingivitis D. Glossitis
A. Stomatitis A client who has stomatitis can have red and inflamed oral mucosa that results in pain. Causes of stomatitis include chemotherapy and opportunistic infections in clients who are immunocompromised.
A nurse is reviewing a client's medication administration record. The nurse should identify that which of the following medications places the client at risk for dry mouth? A. Digoxin B. Gabapentin C. Isosorbide Dinitrate D. Ranitidine
B. Gabapentin A client who takes gabapentin is at risk for dry mouth, increased appetite, nausea, and vomiting.
A nurse is caring for a client who is unconscious and requires oral hygiene. The nurse should place the client in which of the following positions? A. Dorsal recumbent B. Lateral C. Prone D. Trendelenburg
B. Lateral The nurse should position the client in a lateral or side-lying position with the head of the bed flat to facilitate drainage of mouth rinse and prevent aspiration.
A nurse is assessing a clients oral cavity and observes an accumulation of foul matter. Which of the following findings should the nurse document? A. Tartar B. Sordes C. Periodontal disease D. Xerostomia
B. Sordes Sordes is the accumulation of foul matter—such as food, bacteria, and cells—that results from poor oral hygiene.
A nurse is teaching a family member of a client who is unconscious how to provide oral care for the client. The nurse should identify which of the following statements as an indication that the family member understands the teaching? A. "I will use mineral oil to keep her lips moist." B. "I will cleanse her gums with a lemon-glycerin swab." C. "I will use my fingers to keep her mouth open." D. "I will rinse her mouth with an alcohol-free mouthwash."
D. "I will rinse her mouth with an alcohol-free mouthwash." The family member should use a rubber-tipped syringe and gently inject an alcohol-free mouthwash into each side of the client's mouth. The family member should ensure that all of the rinsing solution has drained out of the client's mouth to prevent aspiration.
What action should the nurse taken when performing oral care for a dependent client?
First, introduce yourself, perform hand hygiene, confirm privacy of the client, and confirm identity of the client. After doing this, place the client in a high Fowlers position, you could also place on the side if needed. If the patient is at risk of aspirating, have suction available. Perform hand hygiene and don gloves before starting the procedure. Inspect the clients mouth for any abnormalities, such as lesions or infections. Cover the clients chest with a towel to prevent soiling the client. Cover the toothbrush with water and then add enough toothpaste to cover the brush. Brush the inner and outer of teeth from the gum line to the crown of the teeth. To clean the biting surface brush back and forth parallel to the teeth. After brushing the teeth, brush the tongue, gently. Have the patient rinse teeth by swishing water for a couple seconds. Wipe mouth if necessary. Floss the teeth, gently. have the client swish water once again and clean mouth as needed.
