NHM MP Staff Nurse - 2015
Nursing Foundation
Medium
A patient who is unconscious needs frequent mouth care. When performing mouth care, the best position of the patient is:
Appeared in: NHM MP Staff Nurse - 2015
Explanation
- The side-lying (lateral) position is the correct and safest choice for an unconscious patient.
- This position utilizes gravity to promote the drainage of secretions and cleaning solutions out of the mouth.
- By preventing fluid from pooling in the back of the throat (pharynx), the side-lying position significantly reduces the risk of aspiration.
- An unconscious patient's gag reflex is impaired or absent, making airway protection the top priority during oral care.
Why Other Options Were Wrong
- Option A: In Fowler's position (head of bed elevated), an unconscious patient who cannot control their head or secretions is still at risk. Fluids can pool in the posterior pharynx and be aspirated.
- Option C: The supine position is the most dangerous for this procedure. Lying on the back allows fluids to flow directly down the throat into the airway, posing a very high risk of aspiration.
- Option D: The Trendelenburg position (head lower than feet) is contraindicated. It increases the risk of gastric regurgitation and aspiration and can also dangerously elevate intracranial pressure.
Related Visual
Clinical Relevance
- Nursing practice connection: Use the key finding related to Patient positioning for oral care in unconscious patients to guide bedside assessment, documentation, and the next nursing action.
- Protecting the airway is a fundamental nursing responsibility. Aspiration can lead to aspiration pneumonia, a serious and potentially fatal complication, especially in debilitated patients.
- Frequent and proper oral care in unconscious patients is essential not only for hygiene but also to prevent ventilator-associated pneumonia (VAP) in intubated patients.
- What if? If a patient has a suspected cervical spine injury and cannot be turned onto their side, the procedure must be modified. The nurse would use a log-rolling technique with assistance to gently tilt the patient, or maintain a neutral position and use meticulous, simultaneous oral suctioning to remove all fluids immediately.
How to Approach the Question
- First, identify the patient's condition: 'unconscious'. This is the most important piece of information.
- Recognize the primary risk associated with an unconscious state: the loss of protective airway reflexes, specifically the gag reflex.
- Consider the procedure: 'mouth care' involves introducing fluids into the oral cavity.
- Evaluate each position based on the principles of gravity and airway protection. Ask yourself: 'Which position will prevent fluid from entering the lungs?'
- The side-lying position is the only option that uses gravity to drain fluid away from the airway, making it the safest and therefore the 'best' choice.
Concept Tested & Keywords
- Concept Tested: Patient positioning for oral care in unconscious patients
- Stem keywords: unconscious, mouth care, position
- Lead-in keywords: best position
- Clinical cues: The patient's unconscious state is the most critical factor, as it implies a loss of protective airway reflexes like the gag reflex.
Question ID
QLs6eTxGqErmz_kfi43wrR
Reference Book
E6 Nursing Fundamentals Potter Perry 12e Part 4 pp. 223-225, 194-196, 155-157
Practise the full NHM MP Staff Nurse - 2015
Attempt every question from this paper in a timed mock, then review the full solution for each one.
More Care of altered functioning of sensory organ & Unconscious patient Questions
- A patient is admitted to the emergency department with a decreased level of consciousness. The nurse assesses the patient's airway and determines tha…
- The priority when providing oral hygiene to an unconscious client is to prevent?
- In ICU, a nurse is assisting a doctor for inserting an NG tube into a comatose patient. What position is given to this patient during the procedure?
- Early indicator of hypoxia in an unconscious client?
- Eye padding is applied on unconscious patients to prevent:
- Which of the following is used to access the level of consciousness?
- Mechanical or electrical device that improves hearing?
- Which is a priority responsibility of on duty nurse for a patient who is legally blind?
- Purpose of eye care in a comatose patient is?
- The position to be given to an unconscious patient for mouth care is?
More NHM MP Staff Nurse - 2015 Questions
- Functional unit of Kidney is?
- Malaria is caused by?
- An old patient on chemotherapy begins to cry as the nurse discusses hair loss. The best response would be?
- A patient who is receiving intravenous fluids develops tenderness, warmth, erythematous and pain at the infusion site. Which of the following conditi…
- What electrolyte abnormality is likely to develop in a patient with vomiting?
- Involvement of which of the following structures will lead to right-sided hemiplegia and aphasia?
- Which of the following is an intervention for a patient with chronic obstructive pulmonary disease?
- The International Council of Nurses (ICN) headquarter is located at?
- Discharge plan for diabetic patients includes insulin injection site-rotation. You should emphasize that the space between sites should be?
- A Physician orders penicillin for a patient with streptococcal pharyngitis. The nurse administers the drug and the patient has an allergic reaction.…