a nurse is caring for a client who is receiving intermittent enteral feedings which of the following actions should the nurse take to reduce the risk
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Nursing Elites

ATI RN

ATI Exit Exam 2023

1. A client receiving intermittent enteral feedings is being cared for by a nurse. Which action should the nurse take to reduce the risk of aspiration?

Correct answer: C

Rationale: The correct action to reduce the risk of aspiration during enteral feedings is to elevate the head of the bed to 45 degrees. This position helps prevent the reflux of feeding into the lungs. Administering the feeding over 60 minutes (Choice A) does not directly reduce the risk of aspiration. Positioning the client in a supine position (Choice B) increases the risk of aspiration as it promotes reflux. Flushing the feeding tube with water (Choice D) is important for tube patency but does not directly reduce the risk of aspiration.

2. A nurse is preparing to perform tracheostomy care for a client. Which of the following actions should the nurse take first?

Correct answer: B

Rationale: Suctioning the tracheostomy should be performed first to clear the airway of secretions and ensure proper oxygenation before proceeding with other care. This helps maintain a patent airway and prevent complications such as aspiration. Applying a sterile dressing, removing the inner cannula, or cleaning the stoma can follow after ensuring adequate airway clearance through suctioning.

3. A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following client statements indicates an understanding of the teaching?

Correct answer: A

Rationale: The corrected answer is A. Weighing daily is crucial for clients with heart failure to monitor fluid status since sudden weight gain can indicate fluid retention. Choice B is incorrect because excessive water intake can worsen fluid retention in heart failure. Choice C is incorrect as some physical activity is encouraged for heart failure clients, tailored to their condition. Choice D is incorrect as adjusting medication doses should always be done under healthcare provider guidance rather than self-administration.

4. A nurse is teaching a client who has a new prescription for lisinopril. Which of the following statements should the nurse include?

Correct answer: D

Rationale: The correct statement to include when teaching a client prescribed with lisinopril is that they should avoid using salt substitutes while taking this medication. Lisinopril can cause hyperkalemia, which is an elevated level of potassium in the blood. Therefore, using salt substitutes that contain potassium can worsen this condition. Choices A, B, and C are incorrect because lisinopril is not typically associated with causing a dry cough or a slow heart rate, and increasing potassium intake can be harmful in the presence of lisinopril-induced hyperkalemia.

5. A client who has a new prescription for levothyroxine is being taught by a nurse. Which of the following client statements indicates an understanding of the teaching?

Correct answer: A

Rationale: The correct answer is A: ''I will need to take this medication for the rest of my life.'' Levothyroxine is a lifelong medication for clients with hypothyroidism and should be taken as prescribed. Choice B is incorrect because levothyroxine should not be taken with antacids as they can interfere with its absorption. Choice C is incorrect as iodine-containing foods do not need to be avoided with levothyroxine. Choice D is incorrect because levothyroxine should be stored at room temperature, not in the refrigerator.

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