ATI LPN
LPN Fundamentals of Nursing
1. What is a true statement about caring for a client with a nasogastric (NG) tube?
- A. The NG tube should be flushed with 30 mL of water every 4 hours.
- B. The client should be positioned in a supine position.
- C. The NG tube should be advanced 5 cm if resistance is met.
- D. The client's nasal mucosa should be inspected daily.
Correct answer: A
Rationale: Flushing the NG tube with 30 mL of water every 4 hours is crucial to maintain its patency and prevent blockages. This routine ensures the tube stays clear and functional, enabling proper delivery of medications and nutrition to the client. Regular flushing also helps prevent residue buildup or clogs within the tube, reducing risks like aspiration or inaccurate medication dosing.
2. A client with diverticulitis is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should increase my intake of high-fiber foods.
- B. I should decrease my intake of high-fiber foods.
- C. I should increase my intake of high-fat foods.
- D. I should decrease my intake of high-fat foods.
Correct answer: A
Rationale: The correct answer is A. Increasing intake of high-fiber foods is essential in managing diverticulitis as it helps prevent constipation and promotes bowel regularity, reducing the risk of complications and improving overall colon health. Choice B is incorrect because decreasing high-fiber foods can worsen diverticulitis symptoms. Choices C and D are also incorrect as increasing high-fat foods can exacerbate diverticulitis, while decreasing high-fat foods is generally recommended to manage the condition.
3. A client is receiving continuous enteral feedings through a nasogastric tube. Which of the following actions should the nurse take?
- A. Elevate the head of the bed to 30°
- B. Flush the tube with 50 mL of water every 2 hours
- C. Replace the feeding bag and tubing every 72 hours
- D. Check the client's gastric residual every 8 hours
Correct answer: A
Rationale: Elevating the head of the bed to 30° is the correct action to take when a client is receiving continuous enteral feedings through a nasogastric tube. This position helps prevent aspiration of the enteral feedings into the lungs, reducing the risk of aspiration pneumonia. Additionally, elevating the head of the bed promotes proper digestion and absorption of the feedings by utilizing gravity to facilitate movement into the stomach and through the gastrointestinal tract. Flushing the tube with water every 2 hours (Choice B) is not necessary for continuous feedings and may disrupt the feeding schedule. Replacing the feeding bag and tubing every 72 hours (Choice C) is not the standard recommendation unless there are specific concerns or complications. Checking the client's gastric residual every 8 hours (Choice D) is important but not the immediate action needed to prevent aspiration during enteral feedings.
4. When caring for a client with a hearing impairment, which of the following actions should the nurse take when speaking with the client?
- A. Speak in a high-pitched voice.
- B. Exaggerate lip movements.
- C. Face the client when speaking.
- D. Use a monotone voice.
Correct answer: C
Rationale: When caring for a client with a hearing impairment, it is essential for the nurse to face the client when speaking. By facing the client, the nurse allows the individual to read lips and see facial expressions, which can significantly improve communication effectiveness. This approach facilitates better understanding and helps the client feel more connected during interactions. Speaking in a high-pitched voice (Choice A) is not recommended as it may distort speech sounds. Exaggerating lip movements (Choice B) can be patronizing and ineffective. Using a monotone voice (Choice D) lacks intonation that helps convey meaning and emotions in speech, making it harder for the client to understand.
5. When caring for a client with a prescription for wound irrigation, which action should the nurse take?
- A. Use a 10-mL syringe with an 18-gauge needle.
- B. Cleanse the wound from the center outward.
- C. Apply a wet-to-dry dressing.
- D. Pack the wound tightly with gauze.
Correct answer: B
Rationale: When caring for a client with a prescription for wound irrigation, the nurse should cleanse the wound from the center outward. This technique helps prevent the introduction of microorganisms into the wound, reducing the risk of contamination and promoting effective wound healing. By using a circular motion from the cleanest area to the least clean areas, debris and bacteria are moved away from the wound site, decreasing the chances of infection.
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