For an unconscious patient the method to remove excess secretions from mouth is

Appeared in: NHM UP Staff Nurse-2021 Shift-2nd

Explanation

An unconscious patient has a diminished or absent gag and cough reflex, making them unable to clear their own airway.
Accumulated oral secretions can lead to airway obstruction or be aspirated into the lungs, causing aspiration pneumonia.
Suctioning is the standard medical procedure for mechanically removing secretions from the oropharynx to maintain a patent airway.
Oropharyngeal suctioning is specifically used when a patient can cough but cannot effectively clear secretions by expectorating, or when they are unable to manage secretions at all.

Option B: A bed bath is a hygiene procedure focused on cleaning the skin. It does not address airway patency.
Option C: Early mobilization is a measure to prevent complications of immobility, such as deep vein thrombosis, muscle atrophy, and pressure ulcers.
Option D: Isolation is an infection control protocol used to prevent the transmission of contagious pathogens.

Clinical Relevance

Nursing practice connection: Use the key finding related to Airway management in unconscious patients to guide bedside assessment, documentation, and the next nursing action.
Maintaining a patent airway is the highest priority in patient care (following the ABCs: Airway, Breathing, Circulation). For an unconscious patient, suctioning is a critical, life-saving skill.
Nurses must assess the need for suctioning by observing for gurgling sounds, visible secretions, or signs of respiratory distress. Suctioning should be based on assessment, not a fixed schedule.
Improper suctioning technique can cause harm, including mucosal trauma, bleeding, hypoxia, and cardiac arrhythmias. Adhering to correct pressure settings and time limits is essential for patient safety.

How to Approach the Question

First, identify the core problem presented in the question: an unconscious patient with excess oral secretions.
Recognize the immediate life-threatening risk associated with this problem: airway obstruction and aspiration.
The primary goal, therefore, is to clear the airway.
Evaluate each option based on its ability to achieve this goal.
Suctioning is a direct method to remove secretions from the airway.
Bed bath, early mobilization, and isolation serve other important but unrelated purposes (hygiene, preventing immobility complications, and infection control, respectively).

Concept Tested & Keywords

Concept Tested: Airway management in unconscious patients
Stem keywords: unconscious patient, excess secretions, remove from mouth
Lead-in keywords: method to
Clinical cues: The patient's state of unconsciousness is the key cue, as it implies a loss of protective airway reflexes.

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E6 Nursing Fundamentals Potter Perry 12e Part 5 pp. 1, 13-15

E6 Nursing Fundamentals Potter Perry 12e Part 4 p. 194-196

Practise the full NHM UP Staff Nurse-2021 Shift-2nd

Attempt every question from this paper in a timed mock, then review the full solution for each one.