For an unconscious patient,which of the following interventions are necessary to provide for patient safety? Select all that apply.
A) Talk to the patient as you provide care.
B) Incorporate more touch in the plan of care.
C) Give frequent eye care if blink reflex is absent.
D) Keep the siderails up and bed in low position.
E) Perform diligent oral care by irrigating with diluted mouthwash.

Question

Quizplus · Accepted Answer

Safety measures are a priority for unconscious clients.Keep the bed in low position when you are not at the bedside,and keep the siderails up.If the patient's blink reflex is absent or her eyes do not close totally,you may need to give frequent eye care to keep secretions from collecting along the lid margins.The eyes may be patched to prevent corneal drying,and lubricating eye drops may be ordered.It is important to talk to the patient because the sense of hearing may still be intact.This provides some stimulation and may help with reality orientation.Providing touch will also help prevent sensory deficit; however,it is not a safety measure.The unconscious patient would have a minimal or absent gag reflex and lack of swallowing; therefore,you would not squirt fluid in the mouth for oral care because it could cause the patient to aspirate.

For an Unconscious Patient,which of the Following Interventions Are Necessary