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. Findings during an endoscopic exam include a cobblestone appearance of the colon in your patient. The findings are characteristic of which disorder?

• A. Ulcer
• B. Crohn’s disease
• C. Chronic gastritis
• D. Ulcerative colitis

Correct answer: B

Rationale: The cobblestone appearance of the colon is characteristic of Crohn’s disease.

3. A nurse is providing instructions to a client who will collect a stool specimen for occult blood. The nurse instructs the client to avoid which of the following for 3 days before the collection of the stool specimen?

• A. Milk products
• B. Hard cheese
• C. Turnips
• D. Cottage cheese

Correct answer: C

Rationale: The correct answer is C: Turnips. The nurse would instruct the client to avoid red meat, poultry, fish, turnips, horseradish, and foods such as fruits and vegetables for 3 days before and during testing. These products may alter test results. Choices A, B, and D are incorrect because they are not specifically mentioned as items to avoid before collecting a stool specimen for occult blood.

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

• A. At first, the stoma may bleed slightly when touched.
• B. The stoma should appear dark and have a bluish hue.
• C. A burning sensation under the stoma faceplate is normal.
• D. The stoma should remain swollen away from the abdomen.

Correct answer: A

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

5. A home care nurse is visiting a client with a diagnosis of pernicious anemia that developed as a result of gastric surgery. The nurse instructs the client that because the stomach lining produces a decreased amount of intrinsic factor in this disorder, the client will need

• A. Vitamin B12 injections.
• B. Vitamin B6 injections.
• C. An antibiotic.
• D. An antacid.

Correct answer: A

Rationale: A lack of the intrinsic factor needed to absorb vitamin B12 occurs in pernicious anemia. Vitamin B12 is needed for the maturation of red blood cells. Vitamin B6 is not necessarily needed for pernicious anemia and can be taken orally. An antibiotic and antacids may be prescribed for certain types of gastric ulcers.

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