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. Christina is receiving an enteral feeding that requires a concentration of 80ml of supplement mixed with 20 ml of water. How much water do you mix with an 8 oz (240ml) can of feeding?

• A. 60 ml.
• B. 70 ml.
• C. 80 ml.
• D. 90 ml.

Correct answer: A

Rationale: For an 8 oz (240 ml) can of feeding, mix 60 ml of water to achieve the required concentration.

3. A client is to take one daily dose of ranitidine (Zantac) at home to treat her peptic ulcer. The nurse knows that the client understands proper drug administration of ranitidine when she says that she will take the drug at which of the following times?

• A. Before meals
• B. With meals
• C. At bedtime
• D. When pain occurs

Correct answer: C

Rationale: Ranitidine (Zantac) is best taken at bedtime to reduce stomach acid production overnight.

4. After abdominal surgery, your patient has a severe coughing episode that causes wound evisceration. In addition to calling the doctor, which intervention is most appropriate?

• A. Irrigate the wound & organs with Betadine.
• B. Cover the wound with a saline soaked sterile dressing.
• C. Apply a dry sterile dressing & binder.
• D. Push the organs back & cover with moist sterile dressings.

Correct answer: B

Rationale: Covering the wound with a saline soaked sterile dressing is the most appropriate intervention for wound evisceration.

5. Your patient with peritonitis is NPO and complaining of thirst. What is your priority?

• A. Increase the I.V. infusion rate.
• B. Use diversion activities.
• C. Provide frequent mouth care.
• D. Give ice chips every 15 minutes.

Correct answer: C

Rationale: The correct answer is C: Provide frequent mouth care. In a patient with peritonitis who is NPO and thirsty, the priority is to maintain oral hygiene and provide comfort by moistening the mouth with frequent mouth care. This helps alleviate the sensation of thirst and maintains oral health. Increasing the IV infusion rate (choice A) may not address the patient's discomfort directly related to thirst. Using diversion activities (choice B) is not as critical as addressing the patient's immediate need for oral care. Giving ice chips every 15 minutes (choice D) is not recommended for a patient with peritonitis who is NPO, as it can lead to complications or worsen the condition.

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