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. The nurse is monitoring a client for the early signs of dumping syndrome. Which symptom indicates this occurrence?

• A. Abdominal cramping and pain
• B. Bradycardia and indigestion
• C. Sweating and pallor
• D. Double vision and chest pain

Correct answer: C

Rationale: Sweating and pallor are early signs of dumping syndrome, a condition where food moves too quickly from the stomach to the small intestine.

3. You’re developing the plan of care for a patient experiencing dumping syndrome after a Billroth II procedure. Which dietary instructions do you include?

• A. Omit fluids with meals.
• B. Increase carbohydrate intake.
• C. Decrease protein intake.
• D. Decrease fat intake.

Correct answer: A

Rationale: To manage dumping syndrome, it is important to omit fluids with meals to slow gastric emptying.

4. The nurse is monitoring a client for the early signs and symptoms for dumping syndrome. Which symptom indicates this occurrence?

• A. Abdominal cramping and pain
• B. Bradycardia and indigestion
• C. Sweating and pallor
• D. Double vision and chest pain

Correct answer: C

Rationale: Early manifestations of dumping syndrome occur 5 to 30 minutes after eating. Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.

5. You’re doing preoperative teaching with Gertrude who has ulcerative colitis who needs surgery to create an ileoanal reservoir. Which information do you include?

• A. A reservoir is created that exits through the abdominal wall.
• B. A second surgery is required 12 months after the first surgery.
• C. A permanent ileostomy is created.
• D. The surgery occurs in two stages.

Correct answer: D

Rationale: The surgery to create an ileoanal reservoir occurs in two stages.

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