The nurse is providing oral care to an unconscious patient. Which action should the nurse take?
a. Moisten the mouth using lemon-glycerin sponges.
b. Hold the patient's mouth open with gloved fingers.
c. Use foam swabs to help remove plaque.
d. Suction the oral cavity.
ANS: D
When providing oral hygiene to an unconscious patient, the nurse needs to protect him or her from choking and aspiration. Have two nurses provide care; one nurse does the actual cleaning, and the other caregiver removes secretions with suction equipment. The nurse can delegate nursing assistive personnel to participate. Some agencies use equipment that combines a mouth swab with the suction device. This device can be used safely by one nurse to provide oral care. Commercially made foam swabs are ineffective in removing plaque. Do not use lemon-glycerin sponges because they dry mucous membranes and erode tooth enamel. While cleansing the oral cavity, use a small oral airway or a padded tongue blade to hold the mouth open. Never use your fingers to hold the patient's mouth open. A human bite contains multiple pathogenic microorganisms.
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