Question

The nurse is administering mouth care to an unconscious client. The nurse should perform which actions in the care of this person? Select all that apply.

1.Use products that contain alcohol.
2.Position the client on his or her side.
3.Brush the teeth with a small, soft toothbrush.
4.Cleanse the mucous membranes with soft sponges. 5.Use lemon glycerin swabs when performing mouth care.

Answer 1

For mouth care in an unconscious client, a nurse should gently cleanse the mucous membranes with soft sponges, but avoid lemon glycerin swabs that can disrupt oral environments conducive to the growth of anaerobic microbes.

Step-by-step explanation:

When administering mouth care to an unconscious client, a nurse should ensure the action is performed safely and effectively to prevent infection and maintain oral hygiene. Cleansing the mucous membranes with soft sponges is appropriate, as it is gentle and minimizes the risk of causing trauma to the tissues. The use of lemon glycerin swabs, however, is not recommended because they can potentially lead to mouth dryness and may affect the oral pH, promoting the growth of anaerobic microbes.

It's important to consider that the oral cavity supports a large microbial community, despite the presence of saliva—as it contains enzymes like lysozyme, which damages microbial cells—and other defense mechanisms. During a neurological exam, health care professionals may inspect the oral cavity and pharynx to assess for signs of infection and test the functions of cranial nerves. Thus, maintaining good oral hygiene is critical, especially in unconscious patients who are unable to perform this care themselves.