ATI LPN
LPN Fundamentals of Nursing Quizlet
1. A client is receiving enteral feedings through an NG tube. Which of the following actions should be taken to prevent aspiration?
- A. Monitor gastric residuals every 4 hours.
- B. Position the client in a semi-Fowler's position.
- C. Check for tube placement by auscultating air after feeding.
- D. Warm the formula to body temperature before feeding.
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.
2. When assessing a client with diabetes mellitus experiencing DKA, which of the following findings should the nurse expect?
- A. Tremors
- B. Urine retention
- C. Kussmaul respirations
- D. Bradypnea
Correct answer: C
Rationale: Kussmaul respirations are a type of deep and labored breathing pattern associated with severe metabolic acidosis, commonly observed in diabetic ketoacidosis (DKA). In DKA, the body tries to compensate for the acidic environment by increasing the respiratory rate, resulting in Kussmaul respirations. This helps eliminate excess carbon dioxide and reduce the acidity of the blood. Tremors (Choice A) are not typically associated with DKA. Urine retention (Choice B) is not a common finding in DKA; in fact, clients with DKA often have polyuria due to the osmotic diuresis caused by high blood glucose levels. Bradypnea (Choice D), which is abnormally slow breathing rate, is not a characteristic finding in DKA where the respiratory rate is usually increased to compensate for metabolic acidosis.
3. A client has a stage 1 pressure ulcer on the right heel. Which of the following interventions should the nurse include in the plan?
- A. Apply a heat lamp to the area for 20 minutes each day.
- B. Change the dressing on the heel every 12 hours.
- C. Apply a transparent dressing over the heel.
- D. Use a water pressure mattress.
Correct answer: C
Rationale: Applying a transparent dressing over the heel is beneficial as it can protect the ulcer from friction and shear, and allow for continuous observation of the wound. This intervention promotes healing and prevents further damage to the skin. Choice A is incorrect because applying heat can increase the risk of tissue damage and should be avoided. Choice B is incorrect as changing the dressing every 12 hours may disrupt the wound healing process and is not necessary for a stage 1 pressure ulcer. Choice D is incorrect because using a water pressure mattress is not a specific intervention for a stage 1 pressure ulcer on the heel.
4. A healthcare provider is planning to administer medications to a client who is receiving enteral feedings through an NG tube. Which of the following actions should the healthcare provider plan to take?
- A. Dissolve each medication in 5 mL of sterile water.
- B. Administer medications through a secondary infusion.
- C. Mix medications with the enteral feeding.
- D. Flush the NG tube with 30 mL of water before and after administering medications.
Correct answer: D
Rationale: Flushing the NG tube with water before and after administering medications is essential to prevent clogging of the tube and ensure proper delivery of medication. This practice helps maintain tube patency and decreases the risk of obstruction, which could compromise the client's treatment and nutrition. By flushing the tube, the healthcare provider ensures that the medication is completely delivered and that there are no residual drug particles left in the tube, which could lead to blockages or inconsistent dosing. Therefore, flushing the NG tube is a crucial step in the safe administration of medications to clients receiving enteral feedings. Choices A, B, and C are incorrect. Dissolving medications in sterile water (Choice A) may not be suitable for all drugs, as some medications may require specific diluents. Administering medications through a secondary infusion (Choice B) is not the standard practice for enteral medication administration. Mixing medications with the enteral feeding (Choice C) can cause interactions between medications and the feeding formula, affecting their absorption and effectiveness.
5. A client has tuberculosis, and the nurse is planning care. Which of the following isolation precautions should the nurse implement?
- A. Protective environment
- B. Contact
- C. Airborne
- D. Droplet
Correct answer: C
Rationale: The correct answer is C: Airborne. Tuberculosis is transmitted through the air, making it an airborne disease. Airborne precautions are crucial to prevent the spread of tuberculosis to others. These precautions include placing the client in a negative pressure room, wearing an N95 respirator mask, and ensuring proper ventilation to minimize the risk of transmission to healthcare workers and other clients. Choice A, Protective environment, is used for clients with compromised immune systems. Choice B, Contact precautions, are used for diseases spread by direct or indirect contact. Choice D, Droplet precautions, are for diseases transmitted through respiratory droplets, like influenza or pertussis.
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