LPN LPN
ATI PN Adult Medical Surgical 2019
1. The client has a nasogastric (NG) tube and is receiving enteral feedings. What intervention should the nurse implement to prevent complications associated with the NG tube?
- A. Flush the NG tube with water before and after feedings.
- B. Check gastric residual volume every 6 hours.
- C. Keep the head of the bed elevated at 30 degrees.
- D. Replace the NG tube every 24 hours.
Correct answer: C
Rationale: Keeping the head of the bed elevated at 30 degrees is crucial in preventing aspiration, a common complication associated with nasogastric (NG) tubes and enteral feedings. This position helps reduce the risk of reflux and aspiration of gastric contents into the lungs, promoting client safety and preventing respiratory complications. Flushing the NG tube with water before and after feedings (Choice A) is not the primary intervention to prevent complications. Checking gastric residual volume every 6 hours (Choice B) is important but not directly related to preventing complications associated with the NG tube. Replacing the NG tube every 24 hours (Choice D) is not a standard practice and is not necessary to prevent complications if the tube is functioning properly.
2. A client with a history of myocardial infarction (MI) is prescribed atorvastatin (Lipitor). Which outcome indicates that the medication is effective?
- A. Increased blood pressure.
- B. Lowered cholesterol levels.
- C. Decreased heart rate.
- D. Improved liver function.
Correct answer: B
Rationale: The correct answer is B: Lowered cholesterol levels. Atorvastatin is a medication commonly prescribed to lower cholesterol levels, which is crucial in reducing the risk of further cardiovascular events, including myocardial infarction (MI). Monitoring cholesterol levels is essential to assess the effectiveness of atorvastatin therapy and its role in preventing future cardiac complications. Choices A, C, and D are incorrect because increased blood pressure, decreased heart rate, and improved liver function are not direct indicators of atorvastatin's effectiveness in a client with a history of MI.
3. The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?
- A. Explain that distrust is related to feeling anxious.
- B. Initiate short, frequent contacts with the client.
- C. Explain that these beliefs are related to her illness.
- D. Offer to keep the belongings at the nurse's desk.
Correct answer: B
Rationale: Initiating short, frequent contacts with the client is the most appropriate action to promote trust. This approach helps build trust and rapport, addressing the client's need for security. By maintaining regular contact, the nurse can provide reassurance and support, which can help alleviate the client's anxiety related to her delusional beliefs. Choice A does not directly address the client's need for trust and security. Choice C focuses on the client's illness but does not actively address building trust. Choice D, offering to keep the belongings at the nurse's desk, may not be well-received by the client and could potentially worsen her anxiety and distrust.
4. An 85-year-old male resident of an extended care facility reaches for the hand of an unlicensed assistive personnel (UAP) and tries to kiss her hand several times during his morning care. The UAP reports the incident to the charge nurse. What is the best assessment of the situation?
- A. This behavior can be considered sexual harassment and should be reported to the administration immediately.
- B. The UAP should be reassigned to another group of residents, preferably females only.
- C. The client may be suffering from touch deprivation and needs to know appropriate ways to express his need.
- D. The resident needs to understand the rules regarding unwanted touching of the staff and the consequences.
Correct answer: C
Rationale: In this scenario, the resident's actions of reaching for the UAP's hand and trying to kiss it could indicate a need for touch rather than intentional sexual harassment. The best assessment is to consider the possibility that the client may be experiencing touch deprivation and is seeking appropriate ways to express his need for physical contact. Providing guidance on acceptable ways to seek physical affection can help address the underlying issue and improve the resident's interactions with the staff. Choice A is incorrect because assuming sexual harassment without understanding the context and potential reasons behind the behavior can lead to misinterpretation. Choice B is inappropriate as reassignment based on gender is not a solution and does not address the root cause of the behavior. Choice D is not the best approach as it focuses solely on setting boundaries without considering the resident's underlying need for touch.
5. A client who has been receiving treatment for depression with a selective serotonin reuptake inhibitor (SSRI) reports experiencing decreased libido. What is the best response by the nurse?
- A. Decreased libido is a common side effect of SSRIs and may improve over time.
- B. I will notify your healthcare provider to discuss possible medication changes.
- C. You should take your medication with food to reduce side effects.
- D. Increase your daily exercise to help manage this side effect.
Correct answer: B
Rationale: When a client reports experiencing decreased libido while taking SSRIs, it is important for the nurse to notify the healthcare provider to discuss potential medication adjustments. This side effect can significantly impact a client's quality of life, and addressing it promptly by involving the healthcare provider is crucial in providing holistic care. Choices A, C, and D do not directly address the issue of decreased libido caused by SSRIs. Simply waiting for improvement over time, altering the administration of medication with food, or increasing exercise are not appropriate strategies for managing this specific side effect.
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