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 Penrose drain is in place on the first postoperative day following a cholecystectomy. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate?

Correct answer: B

Rationale: Serosanguineous drainage with a small amount of bile is expected from the Penrose drain for the first 24 hours. Drainage then decreases, and the drain is removed usually within 48 hours. The nurse does not need to notify the physician. A sterile dressing covers the site and should be changed to prevent infection and skin excoriation.

3. Annebell is being discharged with a colostomy, and you’re teaching her about colostomy care. Which statement correctly describes a healthy stoma?

Correct answer: A

Rationale: A healthy stoma may bleed slightly when touched initially, which is normal.

4. The pain of a duodenal ulcer can be distinguished from that of a gastric ulcer by which of the following characteristics?

Correct answer: D

Rationale: Pain on an empty stomach is characteristic of a duodenal ulcer, while pain on eating is characteristic of a gastric ulcer.

5. Which of the following complications is thought to be the most common cause of appendicitis?

Correct answer: A

Rationale: A fecalith is a hardened stool that can block the appendix, leading to inflammation and infection, which is the most common cause of appendicitis.

Similar Questions

Which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy?
Five days after undergoing surgery, a client develops a small-bowel obstruction. A Miller-Abbott tube is inserted for bowel decompression. Which nursing diagnosis takes priority?
A patient who underwent abdominal surgery now has a gaping incision due to delayed wound healing. Which method is correct when you irrigate a gaping abdominal incision with sterile normal saline solution, using a piston syringe?
A client is admitted with a diagnosis of ulcerative colitis. Which of the following symptoms should the nurse expect the client to report when responding to questions about his bowel elimination pattern?
Which of the following types of diets is implicated in the development of diverticulosis?

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