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. Sitty, a 66 y.o. patient underwent a colostomy for ruptured diverticulum. She did well during the surgery and returned to your med-surg floor in stable condition. You assess her colostomy 2 days after surgery. Which finding do you report to the doctor?

Correct answer: A

Rationale: A blanched stoma 2 days after colostomy surgery should be reported to the doctor as it may indicate compromised blood flow.

3. The nurse is reviewing the medication record of a client with acute gastritis. Which medication, if noted on the client’s record, would the nurse question?

Correct answer: B

Rationale: Indomethacin (Indocin) is an NSAID that can aggravate acute gastritis and should be questioned.

4. A client with ulcerative colitis is diagnosed with a mild case of the disease. The nurse doing dietary teaching gives the client examples of foods to eat that represent which of the following therapeutic diets?

Correct answer: C

Rationale: The client with a mild case of ulcerative colitis is often advised to follow a diet low in roughage and avoid milk. This dietary approach helps reduce the frequency of diarrhea in these clients. Therefore, the correct therapeutic diet for the client with ulcerative colitis in this scenario is a low-roughage diet without milk. Choices A, B, and D are incorrect because high-fat, high-protein, and low-roughage with milk diets are not typically recommended for clients with ulcerative colitis, especially those with mild cases.

5. Before administering an intermittent tube feeding through a nasogastric tube, the nurse assesses for gastric residual. The nurse understands that this procedure is important to

Correct answer: D

Rationale: Evaluating the absorption of the last feeding is important because administration of a tube feeding to a full stomach could result in overdistention, thus predisposing the client to regurgitation and possible aspiration.

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