When assisting a patient with oral hygiene, which action is appropriate?

Correct Answer: D

Rationale: Regular mouth care is essential to maintain oral health, prevent infections, and ensure patient comfort, especially for those unable to perform it themselves. Brushing once a week is inadequate daily care is the standard to remove plaque and bacteria. A firm-bristled brush can damage gums, particularly in frail patients, so softer bristles are preferred. Vigorous flossing risks injuring sensitive tissues and isn't suitable for all patients, especially those with limited mobility or cooperation. Regular mouth care, tailored to the patient's needs (e.g., brushing, swabbing, or rinsing), prevents complications like gingivitis or aspiration pneumonia, which are risks in dependent patients. It's a proactive, gentle approach that prioritizes hygiene and safety.

Correct Answer: C

Rationale: A pressure-reducing mattress redistributes body weight to minimize pressure on bony prominences, reducing the risk of pressure ulcers in immobile patients. It enhances blood flow to vulnerable areas like the sacrum or heels, countering the effects of prolonged stillness. Elevating legs might occur with positioning but isn't the mattress's primary role. Exerting pressure for pain relief contradicts its purpose it relieves, not applies, pressure. Immobilizing during sleep isn't the goal; it's about protection, not restraint. Nurses rely on this tool as a proactive measure, complementing repositioning to maintain skin integrity in at-risk patients.

Correct Answer: B

Rationale: Cleansing the area around an indwelling catheter daily with soap and water removes bacteria and debris, preventing urinary tract infections a common catheter complication. Avoiding cleaning invites infection, compromising hygiene. Lotion might trap moisture, fostering bacterial growth, unlike drying after washing. Using the same gloves spreads pathogens, violating infection control. Nurses prioritize this routine to maintain a sterile field, secure the catheter, and reduce irritation, ensuring patient safety and comfort through consistent, evidence-based hygiene practices.

Correct Answer: C

Rationale: Ensuring all straps are snug and secure before using a mechanical lift prevents the patient from slipping or falling during transfer, prioritizing safety for both patient and nurse. Rapid lifting risks jolting or equipment failure. Quick lowering can cause injury or instability. Lifting alone defies safety protocols lifts require teamwork or proper setup, not independence. Nurses double-check fastenings and positioning, following device guidelines, to execute smooth, secure transfers, minimizing harm in patients unable to move themselves.

Correct Answer: D

Rationale: Performing oral care with a soft toothbrush and oral swabs for an unconscious, intubated patient removes plaque and secretions, preventing infections like ventilator-associated pneumonia while protecting delicate tissues. Frequent mouthwash alone doesn't clean mechanically and risks aspiration. Weekly care allows bacterial overgrowth, endangering health. Suctioning without gloves breaches infection control gloves are mandatory. Nurses use these tools gently and regularly, often with suction, to maintain hygiene and comfort, a critical intervention in critical care settings.