a nurse is caring for a client who has a nasogastric tube in place which of the following actions should the nurse take to prevent aspiration

ATI RN

ATI RN Exit Exam Test Bank

1. A nurse is caring for a client who has a nasogastric tube in place. Which of the following actions should the nurse take to prevent aspiration?

A. Elevate the head of the bed 45 degrees during feedings.
B. Place the client in the left lateral position for 30 minutes after feedings.
C. Flush the tube with 30 mL of sterile water before each feeding.
D. Check gastric residuals every 8 hours.

Correct answer: A

Rationale: The correct action to prevent aspiration in a client with a nasogastric tube is to elevate the head of the bed to 45 degrees during feedings. This positioning helps reduce the risk of regurgitation and aspiration of gastric contents. Placing the client in the left lateral position after feedings does not directly prevent aspiration. Flushing the tube with sterile water before each feeding is important for tube patency but does not specifically prevent aspiration. Checking gastric residuals every 8 hours is necessary to monitor the client's tolerance to feedings but is not a direct preventive measure against aspiration.

2. What is the best intervention for a patient with dehydration?

A. Administer IV fluids
B. Provide oral fluids
C. Encourage fluid intake
D. Administer electrolytes

Correct answer: A

Rationale: Administering IV fluids is the best intervention for a patient with dehydration because it is the fastest and most effective way to rehydrate the body. IV fluids can quickly restore fluid volume and electrolyte balance in severe cases of dehydration. Providing oral fluids or encouraging fluid intake may not be sufficient for patients with moderate to severe dehydration, as they may have impaired gastrointestinal absorption. While electrolytes are essential for rehydration, administering them alone without fluid replacement may not address the primary issue of fluid loss in dehydration.

3. A client with a new prescription for furosemide should increase intake of which of the following?

A. You should take this medication on an empty stomach.
B. You should increase your intake of potassium-rich foods.
C. You should take this medication at bedtime.
D. You should avoid taking this medication with food.

Correct answer: B

Rationale: The correct answer is B: 'You should increase your intake of potassium-rich foods.' Furosemide is a potassium-wasting diuretic, which means it can lead to low potassium levels in the body. Increasing intake of potassium-rich foods helps counteract this effect. Choices A, C, and D are incorrect because furosemide should not necessarily be taken on an empty stomach, at bedtime, or specifically avoided with food.

4. A nurse is caring for a client who has cirrhosis and a new prescription for lactulose. The nurse should monitor the client for which of the following therapeutic effects of this medication?

A. Improved mental status.
B. Increased urine output.
C. Decreased serum ammonia.
D. Decreased bilirubin levels.

Correct answer: C

Rationale: The correct answer is C: Decreased serum ammonia. Lactulose is prescribed to decrease serum ammonia levels in clients with cirrhosis and hepatic encephalopathy. By reducing serum ammonia, lactulose helps improve the mental status of these clients. Therefore, monitoring for decreased serum ammonia is crucial to assess the effectiveness of lactulose therapy. Choice A (Improved mental status) is indirectly related as it is the desired outcome of decreasing ammonia levels. Choices B (Increased urine output) and D (Decreased bilirubin levels) are not directly associated with the therapeutic effects of lactulose in cirrhosis and hepatic encephalopathy.

5. How should fluid balance be assessed in a patient receiving diuretics?

A. Monitor daily weight
B. Monitor intake and output
C. Check for edema
D. Monitor blood pressure

Correct answer: A

Rationale: Corrected Rationale: Monitoring daily weight is the most accurate method to assess fluid balance in patients receiving diuretics. Changes in weight reflect changes in fluid balance, making it a sensitive indicator. Monitoring intake and output (choice B) is important but may not provide a complete picture of overall fluid balance. Checking for edema (choice C) is a late sign of fluid imbalance and may not be sensitive enough to detect subtle changes. Monitoring blood pressure (choice D) is relevant but may not directly reflect fluid balance as it can be influenced by various other factors.