A nurse is caring for a client in the intensive care unit who is intubated and mechanically ventilated. Upon assessment, the nurse notes the client has cheilosis. Based on this data, which is the priority intervention for this client?
A) Checking for ill-fitting dentures
B) Suggesting an increase in fluid intake
C) Providing oral care
D) Lubricating the lips using an antimicrobial ointment
Answer: D
Cheilosis is when the lips are cracked. The priority nursing intervention for this client is to lubricate the lips with antimicrobial ointment to prevent infection. The nurse will also provide oral care; however, the lip ointment takes priority. Checking for ill-fitting dentures is appropriate for a client with reddened or excoriated mucosa. Suggesting an increase to the client's fluid intake would be appropriate for a client with dry mucous membranes.
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