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. A nurse is caring for a client diagnose with pancreatitis. The nurse anticipates that the client would not experience an elevation of which of the following enzymes?

Correct answer: B

Rationale: Lactase is produced in the small intestine and aids in splitting neutral fats into glycerol and fatty acids. Lipase, amylase, and trypsin are produced in the pancreas and aid in the digestion of fats, starches, and proteins, respectively.

3. During the first few days of recovery from ostomy surgery for ulcerative colitis, which of the following aspects should be the first priority of client care?

Correct answer: D

Rationale: During the initial recovery period from ostomy surgery, skin care is the first priority to prevent irritation and infection around the stoma site.

4. The nurse would assess the client experiencing an acute episode of cholecystitis for pain that is located in the right:

Correct answer: B

Rationale: Pain from cholecystitis is typically located in the right upper quadrant and may radiate to the right scapula and shoulder.

5. The nurse is caring for a client who underwent a subtotal gastrectomy. To manage dumping syndrome, the nurse should advise the client to:

Correct answer: D

Rationale: A client who experiences dumping syndrome after a subtotal gastrectomy should be advised to ingest liquids between meals rather than with meals. Taking fluids between meals allows for adequate hydration, reduces the amount of bulk ingested with meals, and aids in preventing rapid gastric emptying. There is no need to restrict the amount of fluids, just the time when the client drinks fluids. Drinking liquids with meals increases the risk of dumping syndrome by increasing the amount of bulk and stimulating rapid gastric emptying. Small amounts of water are allowable before meals.

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