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 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

Correct answer: A

Rationale: A lack of 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.

3. A client with a peptic ulcer reports epigastric pain that frequently awakens her at night, a feeling of fullness in the abdomen, and a feeling of anxiety about her health. Based on this information, which nursing diagnosis would be most appropriate?

Correct answer: B

Rationale: Disturbed Sleep Pattern related to epigastric pain is appropriate because the client reports pain that frequently awakens her at night.

4. The nurse is doing pre-op teaching with the client who is about to undergo creation of a Kock pouch. The nurse interprets that the client has the best understanding of the nature of the surgery if the client makes which of the following statements?

Correct answer: A

Rationale: A Kock pouch is a type of continent ileostomy that requires catheterization to empty the internal reservoir. Understanding the need for regular catheterization indicates the client comprehends the procedure.

5. Which of the following associated disorders may the client with Crohn’s disease exhibit?

Correct answer: A

Rationale: Clients with Crohn's disease may exhibit associated disorders such as ankylosing spondylitis, which is an inflammatory condition affecting the spine.

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