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. Which of the following areas is the most common site of fistulas in clients with Crohn’s disease?

Correct answer: A

Rationale: The anorectal area is the most common site of fistulas in clients with Crohn's disease.

3. The nurse is caring for a hospitalized client with a diagnosis of ulcerative colitis. Which finding, if noted on assessment of the client, would the nurse report to the physician?

Correct answer: D

Rationale: Rebound tenderness is a sign of peritonitis, a serious complication that needs to be reported to the physician immediately.

4. A nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis. The client is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment the nurse notes that the abdomen is distended and the bowel sounds are diminished. Which of the following is the most appropriate nursing intervention?

Correct answer: B

Rationale: The symptoms suggest possible perforation or peritonitis, which are serious complications requiring immediate medical attention. The nurse should promptly notify the physician.

5. A client is scheduled for oral cholecystography. Which one of the following actions would the nurse plan to implement before the test?

Correct answer: B

Rationale: Iodine compounds used as radiographic contrast agents, such as iopanoic acid (Telepaque), should not be administered to the client with iodine and seafood allergies because anaphylaxis may occur.

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