a nurse is caring for a client recovering from bowel surgery who has a nasogastric ng tube connected to low intermittent suction which of the followin
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment A

1. A nurse is caring for a client recovering from bowel surgery who has a nasogastric (NG) tube connected to low intermittent suction. Which of the following assessment findings should indicate to the nurse that the NG tube may not be functioning properly?

Correct answer: C

Rationale: Abdominal rigidity can indicate a serious complication, such as a blockage or infection, requiring immediate intervention to determine if the NG tube is functioning properly. Choices A, B, and D are not indicative of a malfunctioning NG tube. Greenish-yellow drainage fluid may be normal, an aspirate pH of 3 is within the expected range for gastric contents, and air bubbles in the NG tube are not abnormal as long as they are moving.

2. A client who is being admitted for induction of labor is receiving teaching about newborn safety from a nurse. Which of the following client statements indicates an understanding of the teaching?

Correct answer: A

Rationale: Choice A is the correct answer because the client should verify the identification badge of anyone removing their baby to ensure the infant's safety and prevent abduction. This statement demonstrates an understanding of the importance of strict identification protocols in the hospital setting. Choice B is incorrect because including a photo of the baby in public announcements does not relate to newborn safety teaching. Choice C is incorrect as it is unsafe to allow a baby to sleep on the bed unsupervised. Choice D is incorrect because nurses typically encourage parents to carry their baby to the nursery themselves for bonding and security reasons.

3. A client with heart failure is receiving discharge teaching. Which statement by the client indicates an understanding of the teaching?

Correct answer: D

Rationale: The correct answer is D. Swelling in the feet can indicate worsening heart failure due to fluid retention, and clients should report this to their healthcare provider immediately. Choices A, B, and C are incorrect because weighing once a week may not provide timely information on fluid retention, timing of diuretic medication is usually advised in the morning to prevent nocturia, and limiting fluid intake to 3 liters per day may not be appropriate for all clients with heart failure.

4. A nurse is caring for a client 4 hours postoperative following a thyroidectomy who reports fullness in the throat. What should the nurse assess for?

Correct answer: B

Rationale: Fullness in the throat after a thyroidectomy could indicate bleeding or a hematoma, which can compress the airway, so hemorrhage is the priority concern. Hypocalcemia typically presents with symptoms like tingling around the mouth or in the extremities, muscle cramps, or seizures, not fullness in the throat. Hypoxia would manifest with symptoms like shortness of breath, confusion, or cyanosis, rather than a feeling of fullness in the throat. Hypothyroidism symptoms include fatigue, weight gain, and cold intolerance, but it does not typically cause acute fullness in the throat postoperatively.

5. A nurse is caring for a client prescribed ferrous sulfate for the treatment of anemia. Which of the following instructions should be included in client teaching about this medication?

Correct answer: A

Rationale: The correct instruction for a client prescribed ferrous sulfate for anemia is to take the medication on an empty stomach. This is because ferrous sulfate is best absorbed in an acidic environment, which is enhanced on an empty stomach. However, if the client experiences gastrointestinal side effects, they can take the medication with food. Choice B, notifying the provider if stool becomes dark green, is correct because dark or black stools are common with iron therapy and not a cause for concern. Choice C, decreasing dietary fiber intake, is incorrect as dietary fiber does not interfere with the absorption of ferrous sulfate. Choice D, taking prescribed antacids at the same time, is incorrect as antacids can decrease the absorption of ferrous sulfate.

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