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. When teaching an elderly client how to prevent constipation, which of the following instructions should the nurse include?

Correct answer: D

Rationale: To prevent constipation, elderly clients should be encouraged to get regular exercise, which promotes bowel motility.

3. Kevin has a history of peptic ulcer disease and vomits coffee-ground emesis. What does this indicate?

Correct answer: C

Rationale: Coffee-ground emesis is a sign of upper gastrointestinal bleeding that occurred approximately 2 hours earlier. It results from the breakdown of blood in the stomach due to digestive enzymes, giving it a coffee-ground appearance. Choice A is incorrect because coffee-ground emesis indicates older, partially digested blood, not fresh active bleeding. Choice B is incorrect as gastric lavage is not indicated for coffee-ground emesis. Choice D is incorrect because a transfusion of packed RBCs is not the immediate management for this presentation.

4. A nurse is providing the client with biliary obstruction a simple overview of the anatomy of the liver and gallbladder. The nurse tells the client that normally the liver stores bile in the gallbladder, which is connected to the liver by the?

Correct answer: C

Rationale: The gallbladder receives bile from the liver through the cystic duct. The liver collects bile in the canaliculi. Bile then flows into the common hepatic duct. From the common hepatic duct, the bile can be stored in the gallbladder through the cystic duct. Otherwise, the bile can flow directly into the duodenum by way of the common bile duct.

5. Kevin has a history of peptic ulcer disease and vomits coffee-ground emesis. What does this indicate?

Correct answer: C

Rationale: Coffee-ground emesis indicates that the gastric bleeding occurred 2 hours earlier.

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