a nurse is assessing a client who has had a nasogastric tube in place for 2 days which of the following findings indicates that the client has develop a nurse is assessing a client who has had a nasogastric tube in place for 2 days which of the following findings indicates that the client has develop
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Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam 2023

1. A client has had a nasogastric tube in place for 2 days. Which of the following findings indicates that the client has developed an adverse effect?

Correct answer: C

Rationale: The correct answer is C, 'Epistaxis.' Epistaxis (nosebleed) is a common adverse effect of prolonged nasogastric tube insertion due to irritation of the nasal mucosa. Dry mucous membranes (choice A) may indicate dehydration but are not a direct adverse effect of nasogastric tube insertion. Polyuria (choice B) is excessive urination and is not typically associated with nasogastric tube insertion. Diarrhea (choice D) is also not a common adverse effect of having a nasogastric tube in place.

2. During a mental status examination, which of the following components should not be included in the assessment?

Correct answer: B

Rationale: During a mental status examination, components such as appearance and behavior, mood and affect, and cognitive function are assessed. Giving advice is not a component of a mental status examination as it focuses on evaluating the client's mental state rather than providing guidance or recommendations.

3. A nurse is providing teaching to an obese client who has gestational diabetes and is at 25 weeks of gestation. Which of the following statements made by the client indicates a need for further teaching?

Correct answer: B

Rationale: The statement 'This means that I will have diabetes for the rest of my life' indicates a need for further teaching. Gestational diabetes often resolves after pregnancy, although it does indicate a higher risk for developing type 2 diabetes in the future. The other choices are correct or provide appropriate information: A) Understanding that gestational diabetes does not mean the baby will have the disease is accurate. C) Advising to drink non-diet soda if feeling dizzy is incorrect and potentially harmful due to the sugar content. D) Recognizing that obesity can be a risk factor for developing diabetes is a valid statement.

4. Which of the following best describes a securely attached child in Japanese culture?

Correct answer: A

Rationale: In Japanese culture, a securely attached child is described as dependent and emotionally restrained. This means that the child relies on their caregiver for support and is able to control their emotions, expressing their feelings in a more subtle and indirect manner. Choice B is incorrect as it describes independence, which is not characteristic of a securely attached child in Japanese culture. Choice C is also incorrect as it describes emotional lability and expressing feelings aggressively, which are not typical of securely attached children. Choice D is incorrect as it combines independence with emotional restraint, which does not align with the characteristics of a securely attached child in Japanese culture.

5. A patient was sneezing frequently after a few days of allergic rhinitis, and she noticed her eye became red. She denies any trauma, eye pain, or visual disturbance. Physical examination reveals a subconjunctival hemorrhage. Which statement is accurate pertaining to this case?

Correct answer: A

Rationale: The correct answer is A: 'The hemorrhage will resolve without treatment within 2 weeks.' Subconjunctival hemorrhage typically resolves on its own without treatment. It is a self-limiting condition that does not require specific intervention. Choice B is incorrect as immediate ophthalmologic examination is not necessary for subconjunctival hemorrhage unless there are other concerning symptoms or risk factors present. Choice C is incorrect because corticosteroid eye drops are not typically used for subconjunctival hemorrhage. Choice D is also incorrect as antibiotic eye drops are not indicated since subconjunctival hemorrhage is not due to an infection.

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