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 student nurse is preparing a teaching care plan to help improve nutrition in a patient with achalasia. You include which of the following:

• A. Swallow foods while leaning forward.
• B. Omit fluids at mealtimes.
• C. Eat meals sitting upright.
• D. Avoid soft and semisoft foods.

Correct answer: C

Rationale: Eating meals while sitting upright helps improve swallowing and prevent complications in patients with achalasia.

3. A nurse is developing a plan of care for a client who will be returning to a nursing unit following a percutaneous transhephatic cholangiogram. The nurse includes which intervention in the postprocedure plan of care?

• A. Place a sandbag over the insertion site.
• B. Allow the client bathroom privileges only.
• C. Encourage fluid intake.
• D. Allow the client to sit in a chair for meals.

Correct answer: A

Rationale: Following this procedure, the nurse monitors the client’s vital signs closely for indications of hemorrhage and observes the needle insertion site for bleeding and bile leakage. A sandbag is placed over the insertion site to prevent bleeding. The client is maintained on bedrest, and oral intake is avoided in the immediate postprocedure period in case surgery is necessary to control hemorrhage of bile extravasation.

4. A client has been diagnosed with adenocarcinoma of the stomach and is scheduled to undergo a subtotal gastrectomy (Billroth II procedure). During pre-operative teaching, the nurse is reinforcing information about the procedure. Which of the following explanations is most accurate?

• A. The procedure will result in enlargement of the pyloric sphincter
• B. The procedure will result in anastomosis of the gastric stump to the jejunum
• C. The procedure will result in removal of the duodenum
• D. The procedure will result in repositioning of the vagus nerve

Correct answer: B

Rationale: The Billroth II procedure involves anastomosis of the gastric stump to the jejunum.

5. You’re patient, post-op drainage of a pelvic abscess secondary to diverticulitis, begins to cough violently after drinking water. His wound has ruptured and a small segment of the bowel is protruding. What’s your priority?

• A. Ask the patient what happened, call the doctor, and cover the area with a water-soaked bedsheet.
• B. Obtain vital signs, call the doctor, and obtain emergency orders.
• C. Have a CAN hold the wound together while you obtain vital signs, call the doctor and flex the patient’s knees.
• D. Have the doctor called while you remain with the patient, flex the patient’s knees, and cover the wound with sterile towels soaked in sterile saline solution.

Correct answer: D

Rationale: For a patient with a ruptured wound and protruding bowel, call the doctor while remaining with the patient, flex the patient’s knees, and cover the wound with sterile towels soaked in sterile saline solution.

Similar Questions