a nurse is caring for a client who has a nasogastric tube and is receiving continuous enteral feedings which of the following actions should the nurse

ATI RN

ATI Comprehensive Exit Exam 2023 With NGN Quizlet

1. A client with a nasogastric tube receiving continuous enteral feedings is at risk for aspiration. Which of the following actions should the nurse take to prevent aspiration?

A. Elevate the head of the bed to 15 degrees
B. Check gastric residual volumes every 6 hours
C. Monitor the pH of gastric aspirate
D. Instill 10 mL of air into the tube before feeding

Correct answer: B

Rationale: Checking gastric residual volumes every 6 hours is essential in preventing aspiration in clients receiving continuous enteral feedings. This practice helps determine if the stomach is adequately emptying, reducing the risk of regurgitation and aspiration. Elevating the head of the bed to 30 degrees, not 15 degrees, is recommended to further prevent aspiration by reducing the risk of reflux. Monitoring the pH of gastric aspirate is important to assess tube placement but does not directly prevent aspiration. Instilling air into the tube before feeding is not a recommended practice and does not prevent aspiration.

2. A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take?

A. Place the client in a negative pressure room.
B. Wear a surgical mask when entering the client's room.
C. Place the client in droplet isolation.
D. Place a surgical mask on the client when transporting them.

Correct answer: A

Rationale: The correct answer is to place the client in a negative pressure room. This action is necessary to prevent the spread of tuberculosis, as it is transmitted via airborne particles. Placing the client in droplet isolation (choice C) is not sufficient for tuberculosis, as it requires airborne precautions. Wearing a surgical mask (choice B) when entering the client's room may not provide adequate protection against airborne transmission. Placing a surgical mask on the client when transporting them (choice D) does not address the need for environmental controls to contain infectious particles.

3. Which lab value is most critical to monitor in a patient receiving digoxin?

A. Monitor potassium levels
B. Monitor sodium levels
C. Monitor calcium levels
D. Monitor magnesium levels

Correct answer: A

Rationale: The correct answer is to monitor potassium levels in a patient receiving digoxin. Hypokalemia can potentiate the toxic effects of digoxin, leading to serious cardiac arrhythmias. Monitoring potassium levels helps prevent toxicity. Monitoring sodium levels (Choice B), calcium levels (Choice C), and magnesium levels (Choice D) are also important aspects of patient care, but potassium levels are most critical in patients on digoxin therapy.

4. A nurse is caring for a client who is 24 hr postpartum and is breastfeeding her newborn. The client asks the nurse to warm up seaweed soup that her partner brought for her. Which of the following responses should the nurse make?

A. Does the doctor know you are eating that?
B. Why are you eating seaweed soup?
C. Of course, I will heat that up for you.
D. The hospital food is more nutritious.

Correct answer: C

Rationale: Respecting cultural preferences and providing client-centered care promotes trust.

5. What is the best way to manage a patient's pain postoperatively?

A. Administer analgesics regularly
B. Administer pain medication PRN
C. Encourage deep breathing exercises
D. Provide distraction techniques

Correct answer: A

Rationale: The correct answer is A: Administer analgesics regularly. Postoperative pain management often requires a scheduled, around-the-clock administration of analgesics to maintain a consistent level of pain relief and minimize the risk of breakthrough pain. Choice B, administering pain medication PRN (as needed), may lead to inadequate pain control as the medication is not given preemptively. Choice C, encouraging deep breathing exercises, can be beneficial for pain management but should be used as an adjunct to analgesic therapy. Choice D, providing distraction techniques, may help some patients cope with pain but should not be the primary method of pain management postoperatively.