NCLEX-PN

Category - Basic Care

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A nurse provides oral care to an unconscious client. Which of the following nursing actions is the most important during oral care?

Turning the client’s head on the side
Use of lemon glycerin in cleaning the client’s teeth and gums
Placing the client in semi-Fowler’s position
Verifying if informed consent is given by the client’s family

Explanation

Answer: A - Before giving oral care, the nurse must place the client in side-lying position or turn the client’s head to one side to prevent aspiration. Lemon glycerin is not recommended, as it can cause tooth decay, whereas placing the client in semi-Fowler’s can increase the risk for aspiration. A special informed consent is not needed when providing oral care.

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