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 nurse is caring for a client who has had a gastroscopy. Which of the following symptoms may indicate that the client is developing a complication related to the procedure? Select all that apply.

• A. The client complains of a sore throat
• B. The client has a temperature of 100*F
• C. The client appears drowsy following the procedure
• D. The client complains of epigastric pain

Correct answer: B

Rationale: A temperature of 100°F, epigastric pain, and hematemesis are signs that may indicate a complication related to the gastroscopy procedure.

3. You’re assessing the stoma of a patient with a healthy, well-healed colostomy. You expect the stoma to appear:

• A. Pale, pink and moist
• B. Red and moist
• C. Dark or purple colored
• D. Dry and black

Correct answer: B

Rationale: A healthy, well-healed colostomy stoma should appear red and moist.

4. The hospitalized client with GERD is complaining of chest discomfort that feels like heartburn following a meal. After administering an ordered antacid, the nurse encourages the client to lie in which of the following positions?

• A. Supine with the head of the bed flat
• B. On the stomach with the head flat
• C. On the left side with the head of the bed elevated 30 degrees
• D. On the right side with the head of the bed elevated 30 degrees.

Correct answer: C

Rationale: Lying on the left side with the head of the bed elevated 30 degrees helps prevent reflux by keeping stomach contents from moving up into the esophagus.

5. The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which of the following laboratory results would the nurse expect to note if the client indeed has appendicitis?

• A. Leukopenia with a shift to the right
• B. Leukocytosis with a shift to the right
• C. Leukocytosis with a shift to the left
• D. Leukopenia with a shift to the left

Correct answer: C

Rationale: Laboratory findings do not establish the diagnosis of appendicitis, but often moderate elevation of the white blood cell count (leukocytosis) to 10,000 to 18,000 cells/mm3 occurs with a “shift to the left” (an increased number of immature white blood cells.).

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