what is the most appropriate strategy for a client with an ng tube who is experiencing nausea and decreased gastric secretions
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Nursing Elites

ATI LPN

ATI PN Comprehensive Predictor 2023 with NGN

1. What is the most appropriate strategy for a client with an NG tube who is experiencing nausea and decreased gastric secretions?

Correct answer: B

Rationale: Irrigating the NG tube with sterile water is the most appropriate strategy for a client with an NG tube experiencing nausea and decreased gastric secretions. This intervention helps in relieving blockages within the tube and can help reduce nausea by ensuring proper drainage. Increasing the suction pressure (Choice A) can lead to complications and should not be done without healthcare provider orders. Turning the client onto their side (Choice C) is a general measure for patient comfort but does not directly address the issue with the NG tube. Replacing the NG tube with a new one (Choice D) is not necessary unless there are specific indications like tube damage or dislodgement.

2. What is an essential nursing intervention for a client experiencing delirium?

Correct answer: B

Rationale: The correct answer is B - 'Identify the underlying causative condition.' When a client is experiencing delirium, it is crucial to determine the root cause of this acute change in mental status. This can involve a thorough assessment to identify any medical conditions, medications, infections, or environmental factors that may be contributing to the delirium. By pinpointing the underlying cause, appropriate interventions can be implemented to address the specific issue. Choices A, C, and D are incorrect because controlling behavioral symptoms with low-dose psychotropics, increasing environmental stimulation, and administering antipsychotic medication do not target the primary need of identifying and addressing the causative condition of delirium.

3. When reviewing the medical record of a client with dementia, what should the nurse prioritize addressing?

Correct answer: B

Rationale: When caring for clients with dementia, addressing restlessness and agitation is a priority as it can lead to distress, safety risks, and potential harm to the client or others. Restlessness and agitation are common behavioral symptoms of dementia and can indicate unmet needs, discomfort, or confusion. Managing these symptoms promptly can help improve the client's quality of life and prevent complications such as falls, injuries, or escalation of challenging behaviors. While other issues like mild confusion, incontinence, and wandering are also important to address, managing restlessness and agitation takes precedence due to its immediate impact on the client's well-being and safety.

4. A nurse is admitting a client who has anorexia nervosa. Which of the following is an expected finding?

Correct answer: B

Rationale: Corrected Rationale: Low prealbumin levels are indicative of malnutrition, which is common in individuals with anorexia nervosa. Iron levels, serum creatinine, and calcium levels are not typically affected in the same way by anorexia nervosa, making choices A, C, and D incorrect.

5. A nurse is caring for a client receiving IV fluids. Which of the following should the nurse do upon noticing phlebitis at the IV site?

Correct answer: C

Rationale: Upon noticing phlebitis at the IV site, the nurse should remove the IV catheter and restart it in another location. Phlebitis is inflammation of the vein, and leaving the IV catheter in place can lead to further complications such as infection. Applying a cold compress (Choice A) may provide temporary relief but does not address the underlying issue. Notifying the provider immediately (Choice B) is important, but the immediate action to prevent complications is to remove the IV catheter. Monitoring the site for signs of infection (Choice D) is necessary, but the priority action is to remove and reinsert the IV catheter to prevent worsening of the phlebitis.

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