the nurse instructs the nursing assistant on how to provide oral hygiene for a client who cannot perform this task for himself which of the following
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Nursing Elites

ATI RN

ATI Gastrointestinal System

1. The nurse instructs the nursing assistant on how to provide oral hygiene for a client who cannot perform this task for himself. Which of the following techniques should the nurse tell the assistant to incorporate into the client’s daily care?

Correct answer: C

Rationale: Swabbing the client’s tongue, gums, and lips with a soft foam applicator every 2 hours helps maintain oral hygiene for a client who cannot perform this task.

2. Stephen is a 62 y.o. patient that has had a liver biopsy. Which of the following groups of signs alert you to a possible pneumothorax?

Correct answer: A

Rationale: Dyspnea and reduced or absent breath sounds over the right lung are signs of a possible pneumothorax.

3. A client with viral hepatitis states, 'I am so yellow.' The nurse most appropriately would

Correct answer: A

Rationale: To assist the client in adapting to changes in appearance, the nurse must encourage participation in self-care to foster independence and self-esteem. The nurse should encourage the client to ask questions to clarify misconceptions, learn ways to prevent the spread of hepatitis to reduce fear, and make appropriate decisions. Restricting visitors will reinforce the client’s negative self-esteem.

4. A client with viral hepatitis is discussing with the nurse the need to avoid alcohol and states, 'I’m not sure I can avoid alcohol.' The most appropriate response is

Correct answer: D

Rationale: The most appropriate response in this situation is to seek clarification from the client by saying, 'I’m not sure that I don’t understand. Would you please explain?' This response shows empathy and a willingness to listen, encouraging the client to elaborate on their concerns. False reassurance (Choice A) is not helpful as it dismisses the client's feelings. Suggesting to talk more with the doctor (Choice B) may deflect from addressing the client's immediate concerns. Expressing disbelief (Choice C) can create a barrier to open communication, making the client feel unsupported.

5. Which of the following factors should be the main focus of nursing management for a client hospitalized for cholecystitis?

Correct answer: B

Rationale: Assessment for complications should be the main focus of nursing management for a client hospitalized for cholecystitis.

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