a nurse is assessing a client who is receiving enteral nutrition via a nasogastric tube which of the following findings should the nurse report to the
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023

1. A nurse is assessing a client who is receiving enteral nutrition via a nasogastric tube. Which of the following findings should the nurse report to the provider?

Correct answer: D

Rationale: A gastric residual of 150 mL may indicate delayed gastric emptying and should be reported to the provider.

2. A nurse is assessing a client who is receiving furosemide for heart failure. Which of the following findings is the priority to report to the provider?

Correct answer: C

Rationale: The correct answer is C. A serum potassium level of 3.2 mEq/L indicates hypokalemia, a potential complication of furosemide therapy, and should be reported immediately. Hypokalemia can lead to serious cardiac dysrhythmias. Choices A, B, and D are important assessments but are not as critical as managing serum potassium levels in a client receiving furosemide for heart failure.

3. A client has a stage 3 pressure injury. Which of the following interventions should the nurse include in the plan?

Correct answer: D

Rationale: The correct intervention for a client with a stage 3 pressure injury is to apply a moisture barrier ointment. This helps protect the skin, maintain moisture balance, and promote healing. Choice A is incorrect because povidone-iodine solution can be too harsh for wound care. Choice B is incorrect as hydrogen peroxide can be cytotoxic to healing tissue. Choice C is important for preventing pressure injuries but is not a direct intervention for a stage 3 wound.

4. A nurse is reviewing the medical record of a client who is receiving gentamicin for a wound infection. Which of the following findings should the nurse report to the provider?

Correct answer: A

Rationale: An elevated BUN level indicates possible nephrotoxicity, which is a side effect of gentamicin and should be reported. Elevated serum creatinine and WBC count are not specifically related to gentamicin therapy. Normal serum glucose levels are also within the expected range.

5. A nurse is providing teaching to a client who has a new prescription for prednisone. Which of the following client statements indicates an understanding of the teaching?

Correct answer: A

Rationale: The correct answer is A: 'I will avoid crowded places to reduce my risk of infection.' When taking prednisone, clients should avoid crowded places to reduce the risk of infection due to its immunosuppressive effects. Choice B is incorrect because prednisone is usually taken with food to reduce stomach upset. Choice C is incorrect because clients should not stop taking prednisone abruptly, even if they experience nausea. Choice D is incorrect because prednisone should be tapered off gradually under healthcare provider guidance instead of being stopped abruptly after 2 weeks.

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