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. Leigh Ann is receiving pancrelipase (Viokase) for chronic pancreatitis. Which observation best indicates the treatment is effective?

• A. There is no skin breakdown.
• B. Her appetite improves.
• C. She loses more than 10 lbs.
• D. Stools are less fatty and decreased in frequency.

Correct answer: D

Rationale: The effectiveness of pancrelipase (Viokase) for chronic pancreatitis is best indicated by stools being less fatty and decreased in frequency.

3. An intubated patient is receiving continuous enteral feedings through a Salem sump tube at a rate of 60ml/hr. Gastric residuals have been 30-40ml when monitored Q4H. You check the gastric residual and aspirate 220ml. What is your first response to this finding?

• A. Notify the doctor immediately.
• B. Stop the feeding, and clamp the NG tube.
• C. Discard the 220ml, and clamp the NG tube.
• D. Give a prescribed GI stimulant such as metoclopramide (Reglan).

Correct answer: B

Rationale: If gastric residuals are high during continuous enteral feedings, the first response is to stop the feeding and clamp the NG tube.

4. Which of the following aspects is the priority focus of nursing management for a client with peritonitis?

• A. Fluid and electrolyte balance
• B. Gastric irrigation
• C. Pain management
• D. Psychosocial issues

Correct answer: A

Rationale: The priority focus of nursing management for a client with peritonitis is fluid and electrolyte balance to prevent shock.

5. The nurse is performing a colostomy irrigation on a client. During the irrigation, a client begins to complain of abdominal cramps. Which of the following is the most appropriate nursing action?

• A. Notify the physician
• B. Increase the height of the irrigation
• C. Stop the irrigation temporarily.
• D. Medicate with dilaudid and resume the irrigation

Correct answer: C

Rationale: If a client experiences abdominal cramps during a colostomy irrigation, it is appropriate to stop the irrigation temporarily to allow the cramps to subside.

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