a nurse is caring for a client who has a nasogastric tube and is receiving continuous enteral feedings which of the following actions should the nurse

ATI RN

ATI Comprehensive Exit Exam 2023 With NGN Quizlet

1. A client with a nasogastric tube receiving continuous enteral feedings is at risk for aspiration. Which of the following actions should the nurse take to prevent aspiration?

A. Elevate the head of the bed to 15 degrees
B. Check gastric residual volumes every 6 hours
C. Monitor the pH of gastric aspirate
D. Instill 10 mL of air into the tube before feeding

Correct answer: B

Rationale: Checking gastric residual volumes every 6 hours is essential in preventing aspiration in clients receiving continuous enteral feedings. This practice helps determine if the stomach is adequately emptying, reducing the risk of regurgitation and aspiration. Elevating the head of the bed to 30 degrees, not 15 degrees, is recommended to further prevent aspiration by reducing the risk of reflux. Monitoring the pH of gastric aspirate is important to assess tube placement but does not directly prevent aspiration. Instilling air into the tube before feeding is not a recommended practice and does not prevent aspiration.

2. A nurse is assessing a client who has pneumonia. Which of the following findings should the nurse report to the provider?

A. Crackles in the lung bases
B. Oxygen saturation of 95%
C. Heart rate of 88/min
D. Frequent productive cough

Correct answer: A

Rationale: The correct answer is A: Crackles in the lung bases. In a client with pneumonia, crackles in the lung bases can indicate fluid accumulation, suggesting worsening respiratory status. This finding should be reported to the provider for further evaluation and management. Choice B, an oxygen saturation of 95%, is within the normal range and does not require immediate reporting. Choice C, a heart rate of 88/min, is also within normal limits and does not indicate an urgent need for intervention. Choice D, a frequent productive cough, is a common symptom in pneumonia and may not require immediate reporting unless it is severe or worsening. Therefore, crackles in the lung bases are the most concerning finding that warrants prompt attention.

3. What is the most important assessment for a patient post-surgery?

A. Monitor vital signs
B. Check surgical site for bleeding
C. Check for abnormal breath sounds
D. Check skin color

Correct answer: A

Rationale: The correct answer is to monitor vital signs post-surgery. Vital signs provide crucial information about a patient's physiological status, helping detect early signs of complications such as shock, bleeding, or infection. Checking the surgical site for bleeding is important but falls secondary to monitoring vital signs, which give a broader overview of the patient's condition. Checking for abnormal breath sounds and skin color are also important assessments, but they are not as immediate and general as monitoring vital signs in detecting various post-surgical complications.

4. Which lab value should be monitored in a patient on digoxin?

A. Monitor potassium levels
B. Monitor calcium levels
C. Monitor digoxin levels
D. Monitor sodium levels

Correct answer: C

Rationale: The correct answer is to monitor digoxin levels in a patient on digoxin. Digoxin is a medication commonly used to treat heart conditions, and monitoring its levels in the blood is crucial to ensure that the patient is within the therapeutic range and to prevent toxicity. Monitoring potassium levels (Choice A) is important due to the potential of digoxin-induced hypokalemia, but the primary focus should be on monitoring digoxin levels. Monitoring calcium levels (Choice B) and sodium levels (Choice D) are not directly related to digoxin therapy and are not the primary lab values of concern when administering digoxin.

5. A nurse is reviewing the medical record of a client who has a new prescription for insulin glargine. Which of the following should the nurse include in the teaching?

A. This insulin has a peak effect of 2 to 4 hours.
B. This insulin has a duration of action of 24 hours.
C. This insulin is given before meals to control your blood sugar.
D. You should avoid eating 30 minutes before or after taking this insulin.

Correct answer: B

Rationale: The correct answer is B. Insulin glargine has a 24-hour duration of action, making it suitable for once-daily dosing for long-term blood sugar control. Choice A is incorrect as insulin glargine is a long-acting insulin with no pronounced peak effect in its action profile. Choice C is incorrect as insulin glargine is usually given at the same time each day regardless of meals. Choice D is incorrect as there is no specific requirement to avoid eating before or after taking insulin glargine.