the nurse supervises care of a client who is receiving enteral feeding via a nasogastric tube the nurse determines that care is appropriate if which
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 3

1. The nurse supervises care of a client who is receiving enteral feeding via a nasogastric tube. The nurse determines that care is appropriate if which of the following is observed? (Select all that apply)

Correct answer: D

Rationale: The correct answer is D because elevating the head of the bed reduces the risk of aspiration, and warming the formula to room temperature helps prevent discomfort and complications. Choice A is incorrect as only licensed healthcare professionals should aspirate and measure the amount of gastric aspirate. Choice B is correct as it helps prevent aspiration. Choice C is correct as warming the formula can prevent discomfort.

2. Which laboratory data indicate the client’s pancreatitis is improving?

Correct answer: A

Rationale: The correct answer is A. Amylase and lipase are enzymes specifically related to pancreatitis. A decrease in their serum levels indicates improvement in pancreatitis. White blood cell count (WBC), choices C and D, are not direct markers for pancreatitis improvement. Bilirubin levels, choice C, are more related to liver function rather than pancreatitis. Blood urea nitrogen (BUN) level, choice D, is a marker for kidney function, not pancreatitis.

3. Clinitest is used in testing the urine of a client for glucose. Which of the following, if committed by a nurse, indicates an error?

Correct answer: C

Rationale: When conducting a Clinitest for testing urinary glucose levels, it is essential to add the correct amounts of urine and Clinitest reagent as instructed. Adding more water than urine could dilute the sample, leading to inaccurate test results. It's important to follow the correct ratio of drops specified in the instructions for an accurate reading.

4. The nurse writes a problem of “potential for complication related to ovarian hyperstimulation” for a client who is taking clomiphene (Clomid), an ovarian stimulant. Which intervention should be included in the plan of care?

Correct answer: B

Rationale: Frequent pelvic sonograms help monitor for ovarian hyperstimulation, a serious potential side effect of clomiphene. Instructing the client to delay intercourse until menses (choice A) is not directly related to monitoring or managing ovarian hyperstimulation. Explaining the duration of infusion therapy (choice C) is not relevant to the potential complication of ovarian hyperstimulation. Discussing the risk of ectopic pregnancy (choice D) is important but not the most appropriate intervention for managing ovarian hyperstimulation.

5. When does short-bowel syndrome usually occur?

Correct answer: B

Rationale: Short-bowel syndrome typically occurs when more than 50% of the small intestine is surgically removed. This condition leads to malabsorption issues due to the reduced length of the intestine for absorption. Choices A, C, and D are incorrect because short-bowel syndrome specifically relates to the insufficient length of the small intestine, not the contraction of longitudinal muscles, surgical removal of the large intestine, or decreased transit time due to infection or drugs.

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