A nurse is providing care for a client who is unconscious following a traumatic brain injury suffered in a motor vehicle accident. The nurse provides thorough oral care to the client on a regular basis
When providing this care, the nurse should take specific action to reduce the client's risk of what nursing diagnosis? A) Risk for Impaired Skin Integrity
B) Risk for Infection
C) Risk for Imbalanced Fluid Volume
D) Risk for Aspiration
D
Feedback:
Unconscious clients are at a heightened risk for aspiration. Consequently, the nurse must ensure that liquids do not enter the client's airway during oral hygiene. Oral hygiene does not constitute a specific risk for infection, fluid imbalance, or impaired skin integrity.
You might also like to view...
A physician asks a nurse to take a smear from herpetic lesions in an older patient's hip to diagnose the disorder. What is the most probable test that will be performed?
a. Culture and sensitivity test to a bactericide b. Tzanck smear to test for viral culture c. Complete blood count to assess the white blood count for response to a pathogen d. Titration for the strength of the pathogen
Which breast change(s) occurs in the first few weeks of pregnancy?
a. enlargement, tingling, and tenderness c. proliferation of lactiferous ducts b. nodular tissue upon palpation d. secretion of colostrum
The most important advice for preventing kidney stones is to
a. restrict dietary calcium intake. b. increase dietary protein intake. c. drink at least 10 to 12 cups of fluid daily. d. achieve and maintain a healthy body weight.
The nurse explains to the pregnant patient that one of the true medical contraindications to breastfeeding is:
1. The mother is HIV-positive. 2. Multiple births 3. The father wants to be involved in feeding the newborn. 4. Pregnant mother