Nursing Elites

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?

• A. Assess the oral cavity each time mouth care is given and record observations
• B. Use a soft toothbrush to brush the client’s teeth after each meal
• C. Swab the client’s tongue, gums, and lips with a soft foam applicator every 2 hours.
• D. Rinse the client’s mouth with mouthwash several times a day.

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. The client with ascites is scheduled for a paracentesis. The nurse is assisting the physician in performing the procedure. Which of the following positions will the nurse assist the client to assume for this procedure?

• A. Supine
• B. Left side-lying
• C. Right side-lying
• D. Upright position.

Correct answer: D

Rationale: An upright position allows the intestine to float posteriorly and helps prevent intestinal laceration during catheter insertion.

3. You’re developing the plan of care for a patient experiencing dumping syndrome after a Billroth II procedure. Which dietary instructions do you include?

• A. Omit fluids with meals.
• B. Increase carbohydrate intake.
• C. Decrease protein intake.
• D. Decrease fat intake.

Correct answer: A

Rationale: To manage dumping syndrome, it is important to omit fluids with meals to slow gastric emptying.

4. Which of the following therapies is not included in the medical management of a client with peritonitis?

• A. Broad-spectrum antibiotics
• B. Electrolyte replacement
• C. I.V. fluids
• D. Regular diet

Correct answer: D

Rationale: A regular diet is not included in the medical management of peritonitis, which requires bowel rest and IV fluids.

5. The nurse is irrigating a client's colostomy when she complains of abdominal cramping after receiving about 100 mL of the irrigating solution. What should the nurse's first response be in this situation?

• A. Stop the flow of solution temporarily.
• B. Reposition the client on to her right side.
• C. Remove the irrigation tube.
• D. Massage the abdomen gently.

Correct answer: A

Rationale: The abdominal cramping that can occur during colostomy irrigation results from stimulation of the colon by the irrigating solution. The nurse's first response should be to temporarily stop the flow of solution to allow the cramping to subside. Repositioning the client to the right side will not alleviate the cramping. Removing the tube will not decrease the cramping and will necessitate reinsertion of the tube when the irrigation is resumed. Massaging the abdomen gently may be soothing to some clients, but it is not the nurse's first priority action.

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