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

ATI RN

ATI RN Exit Exam Test Bank

1. A client with a nasogastric tube receiving intermittent enteral feedings should be positioned in which way?

Correct answer: C

Rationale: Positioning the client with the head of the bed elevated at 45 degrees is crucial during enteral feedings to prevent aspiration. This position helps reduce the risk of regurgitation and aspiration of feedings into the lungs. Option A is not necessary before feedings. Placing the client in a supine position (Option B) increases the risk of aspiration. Checking gastric residuals every 8 hours (Option D) is important but not directly related to positioning during enteral feedings.

2. A client with a new diagnosis of hypertension is being taught about lifestyle changes by a nurse. Which of the following recommendations should the nurse include?

Correct answer: A

Rationale: The correct recommendation for a client with hypertension is to limit sodium intake to no more than 1,500 mg per day. This helps manage hypertension by reducing fluid retention and lowering blood pressure. Choice B is a good recommendation as well, but the primary focus for hypertension management in this scenario is limiting sodium. Choices C and D are incorrect as dairy products and carbohydrates are not directly linked to hypertension.

3. A healthcare provider is providing dietary teaching to a client who has a new diagnosis of hypertension. Which of the following foods should the provider recommend?

Correct answer: C

Rationale: The correct answer is lean beef because it is a good source of protein and essential nutrients. When providing dietary recommendations to clients with hypertension, it is important to focus on lean protein sources to promote a balanced diet. Bananas, although a healthy fruit, may not be the best choice due to their high potassium content, which can sometimes be a concern for individuals with hypertension. Whole grains are generally a good choice, but lean protein like beef is more suitable in this scenario. Canned soup often contains high levels of sodium, which is not recommended for individuals with hypertension.

4. A nurse is planning care for a client who has a new diagnosis of heart failure. Which of the following interventions should the nurse include in the plan of care?

Correct answer: C

Rationale: The correct intervention the nurse should include in the plan of care for a client with heart failure is to monitor the client's weight daily. Daily weight monitoring is essential to assess fluid balance and detect any signs of worsening heart failure. Limiting fluid intake to 1,500 mL per day (Choice A) may be appropriate in some cases, but it is not the initial priority for this client. Encouraging the client to walk every 2 hours (Choice B) is generally beneficial for mobility but may not be directly related to managing heart failure. Administering oxygen via nasal cannula at 2 L/min (Choice D) is a supportive measure for hypoxia but does not directly address heart failure management.

5. How should signs of infection in a post-surgical patient be assessed?

Correct answer: A

Rationale: Assessing the surgical site is crucial in identifying early signs of infection post-surgery. Changes such as redness, swelling, warmth, or drainage may indicate an infection developing. While monitoring vital signs and fever are important in infection assessment, they are general indicators and may not show localized signs at the surgical site. Checking for abnormal breath sounds is more relevant when assessing respiratory issues rather than infection at the surgical site.

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