LPN LPN
LPN Fundamentals of Nursing Quizlet
1. A client is receiving continuous enteral feedings. Which of the following interventions should the nurse implement?
- A. Monitor intake and output every 8 hours.
- B. Flush the feeding tube every 4 hours.
- C. Measure the client's temperature every 24 hours.
- D. Change the feeding bag and tubing every 72 hours.
Correct answer: B
Rationale: The correct answer is B: Flush the feeding tube every 4 hours. Flushing the feeding tube every 4 hours is essential to maintain patency and prevent clogging, ensuring the client receives the prescribed enteral nutrition without interruption. This intervention helps prevent complications such as tube occlusion. Monitoring intake and output is important for assessing the client's hydration status but does not directly address tube patency. Measuring the client's temperature is essential for monitoring for signs of infection but is not directly related to tube maintenance. Changing the feeding bag and tubing every 72 hours is important for infection control but does not address tube patency.
2. A client has been on bed rest for 3 days. Which of the following findings should the nurse identify as an indication that the client is ready to ambulate?
- A. The client uses a walker to move from the bed to the chair.
- B. The client has a strong cough.
- C. The client can bear weight on both legs.
- D. The client has a normal respiratory rate.
Correct answer: C
Rationale: The ability to bear weight on both legs indicates muscle strength and stability necessary for ambulation. This skill is crucial for the client to support their body weight and move independently when standing or walking. Choices A, B, and D are incorrect because using a walker, having a strong cough, or having a normal respiratory rate do not directly indicate the readiness to ambulate. The key factor in determining readiness for ambulation is the client's ability to bear weight on both legs, demonstrating the necessary strength for standing and walking.
3. A client is receiving enteral feedings through an NG tube. Which of the following actions should be taken to prevent aspiration?
- A. Monitor gastric residuals every 4 hours.
- B. Position the client in a semi-Fowler's position.
- C. Check for tube placement by auscultating air after feeding.
- D. Warm the formula to body temperature before feeding.
Correct answer: A
Rationale: Monitoring gastric residuals every 4 hours is essential to assess the stomach's ability to empty properly, reducing the risk of aspiration. It helps in determining if the feedings are being tolerated by the client and if adjustments are needed in the feeding regimen. Positioning the client in a semi-Fowler's position helps prevent reflux and aspiration by promoting proper digestion and emptying of the stomach contents. Checking for tube placement by auscultating air after feeding confirms correct tube placement in the stomach. Warming the formula to body temperature before feeding enhances client comfort but does not directly prevent aspiration. Therefore, the correct answer is to monitor gastric residuals to prevent aspiration, as it directly assesses the stomach's ability to empty properly and the tolerance of the feedings.
4. A client is being assessed for dehydration. Which of the following findings should the nurse expect?
- A. Elevated blood pressure
- B. Increased skin turgor
- C. Dark-colored urine
- D. Bradypnea
Correct answer: C
Rationale: Dark-colored urine is a common sign of dehydration as the urine becomes concentrated. Dehydration leads to reduced fluid intake or excessive fluid loss, causing the urine to be darker in color due to increased urine concentration. Elevated blood pressure (Choice A) is not typically associated with dehydration; instead, dehydration often leads to low blood pressure. Increased skin turgor (Choice B) is actually a sign of good hydration, not dehydration. Bradypnea (Choice D), which refers to abnormally slow breathing, is not a common finding in dehydration.
5. A healthcare professional is educating a client with osteoporosis about dietary management. Which of the following foods should the professional recommend?
- A. Green beans
- B. Fortified cereal
- C. Red meat
- D. White bread
Correct answer: B
Rationale: Fortified cereal is the correct answer as it is an excellent choice for individuals with osteoporosis due to its high calcium and vitamin D content, both essential nutrients for bone health. These nutrients help in maintaining bone density and strength, which is crucial for individuals with osteoporosis. Green beans (choice A) do not provide as much calcium and vitamin D as fortified cereal. Red meat (choice C) is a good source of protein but is not as rich in calcium and vitamin D compared to fortified cereal. White bread (choice D) lacks the essential nutrients needed for bone health, making it a less suitable choice for individuals with osteoporosis.
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