Performing Oral Hygiene for an Unconscious Patient

What is the primary reason an unconscious patient is placed in the side-lying position when mouth care is provided? A. To make the oral cavity easily accessible B. To prevent possible musculoskeletal injury C. To reduce plaque buildup in the mouth D. To reduce the risk of aspiration

To reduce the risk of aspiration Rationale: An unconscious patient is placed in the side-lying position when mouth care is provided because this position prevents pooling of secretions at the back of the oral cavity, thereby reducing the risk of aspiration. Although the side-lying position does allow the nurse to reach the oral cavity easily, accessibility, reducing the risk of musculoskeletal injury, and the reduction of plaque buildup in the mouth are not the reasons this position is used.

The nurse is planning to insert an oral airway into an unconscious patient before performing mouth care. In which direction is the airway initially inserted into the patient's mouth? A. Upside down, or with the curve facing up B. Right side up, or with the curve facing down C. With the curve angled toward the patient's left cheek D. With the curve angled toward the patient's right cheek

Upside down, or with the curve facing up Rationale: The oral airway should be inserted upside down into the patient's mouth, and then turned sideways and over the tongue to keep the teeth apart. The oral airway should not be inserted right side up, because the curve must fit over the patient's tongue. The curve cannot be angled toward the patient's cheek.

When preparing to provide mouth care to a patient who is in a coma, the nurse first ensures patient safety by doing what? A. Assessing the patient's gag reflex B. Inspecting the patient's oral cavity C. Placing the bed in a flat position D. Connecting the suction equipment

Assessing the patient's gag reflex Rationale: Assessing the patient's gag reflex by placing a tongue blade on the back half of the tongue reduces the risk of choking by determining the patient's ability to swallow before mouth care is administered. The nurse inspects the oral cavity after assessing the patient's gag reflex. The nurse places the bed in a flat position before providing mouth care but after assessing the gag reflex. Suction equipment might be needed if the nurse first determines that the patient has an absent or poor gag reflex.

What must the nurse avoid when brushing the tongue of an unconscious patient? A. Dislodging bacteria B. Stimulating the gag reflex C. Moistening the oral mucosa D. Using suction

Stimulating the gag reflex Rationale: If the patient has a gag reflex, the nurse must be careful not to stimulate it while brushing the back of the tongue, since gagging could cause aspiration of secretions. Dislodging bacteria so that it can be removed and moistening mucosa are primary reasons for brushing the tongue. Suction may be used to remove oral secretions and bacteria as the tongue is brushed.

When brushing the teeth of an unconscious patient, why is the toothbrush held so that its bristles are at a 45-degree angle to the gum line? A. To give the nurse a firm grip on the brush handle B. To ensure that the bristles reach all tooth surfaces C. To allow the bristles to reach beneath the gum line D. To reduce pressure on sensitive oral tissues

To allow the bristles to reach beneath the gum line Rationale: The toothbrush is held at this angle to allow the bristles to sweep away plaque beneath the gum line. Holding the toothbrush so that its bristles are at a 45-degree angle does not necessarily ensure a firm grip on the brush handle, allow the bristles to reach all tooth surfaces or reduce pressure on sensitive oral tissues.