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. The nurse develops a plan of care for a client with a T tube. Which one of the following nursing interventions should be included?

Correct answer: A

Rationale: The correct nursing intervention to include in the plan of care for a client with a T tube is to inspect the skin around the T tube daily for irritation. Bile is erosive and can cause skin irritation, so it is crucial to keep the skin clean and dry. T tubes are not routinely irrigated; irrigation is done only with a physician's order. It is unnecessary to maintain the client in a supine position; instead, assist the client into a position of comfort. T tubes are not typically clamped unless ordered by a physician, and if clamped, it is usually done 1 to 2 hours before and after meals.

3. A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported to his physician. Based on this information, which nursing diagnosis would be appropriate for this client?

Correct answer: B

Rationale: Deficient knowledge related to unfamiliarity with significant signs and symptoms is appropriate because the client did not report the black stools, which can be a sign of bleeding.

4. A client with a peptic ulcer is scheduled for a vagotomy. The client asks the nurse about the purpose of this procedure. The nurse tells the client that the procedure:

Correct answer: D

Rationale: A vagotomy reduces the stimulus to acid secretions by cutting the vagus nerve, which innervates the stomach.

5. The nurse is reviewing the medication record of a client with acute gastritis. Which medication, if noted on the client’s record, would the nurse question?

Correct answer: B

Rationale: Indomethacin (Indocin) is an NSAID that can aggravate acute gastritis and should be questioned.

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