a nurse is caring for a patient with a nasogastric ng tube what is the most appropriate intervention to prevent aspiration
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Nursing Elites

ATI RN

ATI Capstone Comprehensive Assessment B

1. When caring for a patient with a nasogastric (NG) tube, what is the most appropriate intervention to prevent aspiration?

Correct answer: C

Rationale: Elevating the head of the bed to 30-45 degrees is the most appropriate intervention to prevent aspiration in a patient with an NG tube. This position helps reduce the risk of regurgitation and aspiration by promoting the proper flow of contents through the gastrointestinal tract and minimizing the chances of stomach contents entering the airway. Flushing the NG tube with water before each feeding may not directly prevent aspiration. Checking the placement of the NG tube is important but does not specifically address the prevention of aspiration. Providing oral care every 4 hours is essential for maintaining oral hygiene but is not directly related to preventing aspiration in a patient with an NG tube.

2. A nurse manager assigns a new nurse to care for a client with unstable blood pressure. What is the nurse's priority action?

Correct answer: B

Rationale: The correct answer is to recheck the blood pressure before calling for help. When caring for a client with unstable blood pressure, the nurse's priority is to ensure an accurate assessment. Rechecking the blood pressure will confirm the instability and guide further actions. Asking the charge nurse for assistance (Choice A) is important but should come after assessing the situation. Monitoring the client's blood pressure closely (Choice C) is essential, but the immediate action should be to recheck and confirm the current status. Administering antihypertensive medication immediately (Choice D) without a confirmed assessment can be dangerous and is not the initial priority.

3. When teaching a patient with a new prescription for brimonidine to treat open-angle glaucoma, what indicates an understanding of the instructions?

Correct answer: C

Rationale: The correct answer is C. When using brimonidine to treat open-angle glaucoma, patients may experience temporary irritation in the eyes. Choice A is incorrect because vision improvement from brimonidine is not immediate. Choice B is incorrect as brimonidine should be used as prescribed, not just when eyes are irritated. Choice D is important but does not directly indicate an understanding of the medication's use.

4. A healthcare provider is reviewing a client's lab results. Which of the following lab values should the provider report?

Correct answer: C

Rationale: The correct answer is C: Sodium 126 mEq/L. A sodium level of 126 mEq/L is below the normal range, indicating hyponatremia, which can have serious health implications and should be reported to the healthcare provider for further evaluation and intervention. Choices A, B, and D are within or close to the normal ranges for magnesium, potassium, and chloride, respectively, and do not require immediate reporting as they are not significantly abnormal.

5. A client in her first trimester of pregnancy is being taught by a nurse about over-the-counter medications that belong to pregnancy risk category B. Which of the following medications should the nurse include?

Correct answer: D

Rationale: Acetaminophen is the correct choice as it belongs to pregnancy risk category B, making it considered safe during pregnancy. Naproxen, Aspirin, and Ibuprofen are not recommended during pregnancy, especially in the first trimester, as they are classified in higher-risk categories which may be harmful to the developing fetus.

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