a nurse is caring for a patient with a nasogastric ng tube what is the most appropriate intervention to prevent aspiration
Logo

Nursing Elites

ATI RN

ATI Capstone Comprehensive Assessment B

1. When caring for a patient with a nasogastric (NG) tube, what is the most appropriate intervention to prevent aspiration?

Correct answer: C

Rationale: Elevating the head of the bed to 30-45 degrees is the most appropriate intervention to prevent aspiration in a patient with an NG tube. This position helps reduce the risk of regurgitation and aspiration by promoting the proper flow of contents through the gastrointestinal tract and minimizing the chances of stomach contents entering the airway. Flushing the NG tube with water before each feeding may not directly prevent aspiration. Checking the placement of the NG tube is important but does not specifically address the prevention of aspiration. Providing oral care every 4 hours is essential for maintaining oral hygiene but is not directly related to preventing aspiration in a patient with an NG tube.

2. A health care provider asks the nurse to administer a medication with a dosage significantly higher than usual. What is the nurse's first action?

Correct answer: B

Rationale: When a health care provider orders a medication with a dosage significantly higher than usual, the nurse's initial action should be to question the provider and verify the dose. This is crucial to ensure patient safety and prevent medication errors. Administering the medication as ordered (Choice A) without clarification could potentially harm the patient if there was an error in the prescription. Administering half the dosage as a precaution (Choice C) is not a safe practice as it deviates from the prescribed order. Refusing to administer the medication without clarification (Choice D) is important, but the first step should be to seek clarification from the provider to prevent any unnecessary delays in patient care.

3. A nurse is providing teaching to a client who has schizophrenia about thioridazine. Which of the following instructions should the nurse include?

Correct answer: A

Rationale: The correct answer is A: 'Report any sign of infection to the provider immediately.' This instruction is essential for clients taking thioridazine or other antipsychotic medications. Thioridazine does not typically affect blood pressure or cause easy bruising. Muscle rigidity is more commonly associated with other antipsychotic medications. Reporting signs of infection promptly is crucial as antipsychotic medications can affect the immune system, making individuals more susceptible to infections. Early detection and treatment of infections help prevent complications and ensure proper medication management.

4. A nurse enters a client's room to administer a prescribed medication, and the client asks about the medication. What is the most appropriate response by the nurse?

Correct answer: B

Rationale: The most appropriate response for the nurse when a client asks about a medication is to refer the client to the healthcare provider for more information. This ensures that the client receives accurate and detailed information from the appropriate source. Providing detailed information or a brief explanation as choices A and C suggest may not be within the nurse's scope of practice and could potentially lead to misinformation or confusion. Asking another nurse to explain the medication, as in choice D, may not guarantee accurate information, so it is best to involve the healthcare provider directly.

5. A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?

Correct answer: C

Rationale: The priority action for the nurse is to determine the reasons why the client is refusing to use the incentive spirometer. By understanding the client's concerns or issues, the nurse can address them effectively, provide education or support, and encourage the client to comply with the necessary postoperative care. This approach fosters a patient-centered care environment. Demonstrating how to use the spirometer (Choice A) may be important but is not the priority at this moment. Setting a realistic postoperative goal (Choice B) is relevant but not as immediate as understanding the client's refusal. Requesting a respiratory therapist (Choice D) can be considered later if needed, but the nurse's initial focus should be on understanding the client's perspective.

Similar Questions

A nurse manager is asked to select clients for early discharge from the unit following a mass casualty event. Which of the following clients should the nurse manager recommend?
What is the most appropriate action for a healthcare professional to take when a medication error occurs?
The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care?
A forensic nurse is using the epidemiological triangle to explain factors that contribute to violent behavior. Which of the following factors should the nurse identify as an environmental factor in the epidemiological triangle?
What is the recommended procedure for a healthcare professional to follow when applying sterile gloves?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses