which of the following statements is true about the care of a client with a nasogastric ng tube
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Nursing Elites

ATI LPN

LPN Fundamentals of Nursing

1. What is a true statement about caring for a client with a nasogastric (NG) tube?

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 healthcare professional is supervising a newly licensed colleague who is preparing to administer an intramuscular injection. Which of the following actions by the newly licensed colleague requires intervention?

Correct answer: B

Rationale: The correct answer is B. Administering an intramuscular injection at a 90° angle is essential for proper medication delivery into the muscle tissue. Injecting at a 45° angle is incorrect for intramuscular injections and is typically used for subcutaneous injections where the needle is inserted into the fatty tissue layer beneath the skin. Choice A is correct as selecting a 25-gauge needle is appropriate for an intramuscular injection. Choice C is also correct as the ventrogluteal site is a suitable site for intramuscular injections. Choice D is correct as aspirating for blood return is a necessary step to ensure the needle is not in a blood vessel before injecting the medication.

3. A client is receiving enteral feedings through an NG tube. Which of the following actions should be taken to prevent aspiration?

Correct answer: A

Rationale: Monitoring gastric residuals every 4 hours is essential to assess the stomach's ability to empty properly, reducing the risk of aspiration. It helps in determining if the feedings are being tolerated by the client and if adjustments are needed in the feeding regimen. Positioning the client in a semi-Fowler's position helps prevent reflux and aspiration by promoting proper digestion and emptying of the stomach contents. Checking for tube placement by auscultating air after feeding confirms correct tube placement in the stomach. Warming the formula to body temperature before feeding enhances client comfort but does not directly prevent aspiration. Therefore, the correct answer is to monitor gastric residuals to prevent aspiration, as it directly assesses the stomach's ability to empty properly and the tolerance of the feedings.

4. During an admission interview, a nurse is assessing a client's personal identity. Which of the following questions should the nurse ask?

Correct answer: B

Rationale: When assessing personal identity, it is important to ask questions that prompt clients to describe themselves. Question B, 'How would you describe yourself?' is the most appropriate as it allows the client to share their own perceptions and characteristics, aiding in understanding their personal identity. Choices A, C, and D are more focused on specific personal details such as marital status, employment status, and parental status, which do not directly contribute to understanding personal identity.

5. When admitting a client at risk for falls in a long-term care facility, what should the nurse do first?

Correct answer: A

Rationale: The initial step in caring for a client at risk for falls is to conduct a fall-risk assessment. This assessment helps the nurse gather crucial data to identify specific risks and individualized needs, guiding subsequent interventions and preventive measures. By completing a thorough assessment, the nurse can develop a targeted plan of care to mitigate fall risk and ensure the client's safety. Placing a fall-risk identification bracelet, providing nonskid footwear, or setting the bed to the lowest position may be important interventions, but these actions should be based on the findings of the fall-risk assessment, making choice A the priority.

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