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 client is receiving morphine for pain management. Which of the following findings should the nurse report to the provider?

Correct answer: C

Rationale: A respiratory rate of 10/min indicates respiratory depression, a serious adverse effect of morphine that should be reported immediately. While a heart rate of 88/min, pain rating of 4, and a temperature of 37.2°C (99°F) are within normal ranges and do not indicate immediate concern related to morphine administration.

3. A client has a new prescription for spironolactone. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct answer is B because spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium. Instructing the client to avoid foods high in potassium helps prevent hyperkalemia, a potential side effect of spironolactone. Choice A is incorrect because taking spironolactone with a potassium supplement can increase the risk of hyperkalemia. Choice C is not directly related to spironolactone use. Choice D is also incorrect as spironolactone does not need to be taken on an empty stomach.

4. A nurse is caring for a client who is 2 hours postoperative following a thoracotomy. Which of the following findings should the nurse report to the provider?

Correct answer: C

Rationale: The correct answer is C. Chest tube drainage of more than 100 mL/hr may indicate active bleeding, which is a serious complication post-thoracotomy surgery. This finding should be reported to the healthcare provider immediately for further evaluation and intervention. Choices A, B, and D are within normal limits for a client 2 hours post-thoracotomy and do not require immediate reporting. Oxygen saturation of 95% is acceptable, and a heart rate of 88/min is within the normal range for an adult.

5. A nurse is caring for a client who is 3 days postoperative following a bowel resection. Which of the following findings should the nurse report to the provider?

Correct answer: C

Rationale: A temperature of 37.8°C (100°F) should be reported to the provider as it can indicate infection, a common postoperative complication. A normal heart rate of 80/min (Choice A), white blood cell count of 9,000/mm3 (Choice B), and blood pressure of 118/78 mm Hg (Choice D) are within normal ranges and do not necessarily indicate a complication postoperatively.

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