a nurse is planning care for a client who has a nasogastric tube for enteral feedings which of the following interventions should the nurse include to
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Nursing Elites

ATI RN

ATI RN Comprehensive Exit Exam

1. A nurse is planning care for a client who has a nasogastric tube for enteral feedings. Which of the following interventions should the nurse include to prevent aspiration?

Correct answer: C

Rationale: Elevating the head of the bed to 45 degrees during feedings is the correct intervention to prevent aspiration in clients with a nasogastric tube. This position helps reduce the risk of regurgitation and subsequent aspiration of stomach contents into the lungs. Flushing the tube with water before feedings (Choice A) is not necessary for preventing aspiration. Checking for gastric residuals (Choice B) helps monitor feeding tolerance but does not directly prevent aspiration. Placing the client in the left lateral position (Choice D) is not specifically indicated for preventing aspiration in a client with a nasogastric tube.

2. A nurse is caring for a client who is in labor and is receiving oxytocin. Which of the following findings indicates that the nurse should increase the rate of infusion?

Correct answer: D

Rationale: The correct answer is D because contractions every 5 minutes that last 30 seconds indicate that the rate of infusion should be increased. This pattern suggests weak contractions or intervals that are too far apart, requiring an adjustment to improve labor progress. Option A is incorrect as a low urine output is not directly related to the need for an increase in the oxytocin infusion rate. Option B, Montevideo units consistently at 300 mm Hg, is incorrect because it is a measure of intrauterine pressure and does not determine the need for an increase in oxytocin infusion. Option C, FHR pattern with absent variability, is incorrect as it may indicate fetal distress but does not specifically relate to the need for adjusting the oxytocin infusion rate.

3. A nurse is caring for a client who has a wound infection and is receiving gentamicin. Which of the following laboratory values should the nurse monitor to detect an adverse effect of this medication?

Correct answer: A

Rationale: The correct answer is A: Creatinine. Gentamicin can cause nephrotoxicity, leading to impaired kidney function. Monitoring creatinine levels helps the nurse detect any potential kidney damage. Choice B, Aspartate aminotransferase (AST), is not typically affected by gentamicin. Choice C, White blood cell count, is not directly related to gentamicin adverse effects. Choice D, Serum glucose, is not specifically monitored for gentamicin adverse effects.

4. A nurse is planning care for a client who has pneumonia. Which of the following interventions should the nurse include to promote airway clearance?

Correct answer: A

Rationale: Encouraging the client to increase fluid intake is essential to promote airway clearance in pneumonia. Adequate hydration helps to thin respiratory secretions, making them easier to expectorate. Suctioning every 2 hours may be too frequent and can lead to airway trauma and irritation. Chest physiotherapy is not typically indicated for pneumonia unless there are specific complications. Administering oxygen via nasal cannula may be necessary to maintain oxygen saturation but does not directly promote airway clearance.

5. A nurse is caring for a client who has a prescription for a clear liquid diet. Which of the following items should the nurse offer to the client?

Correct answer: C

Rationale: The correct answer is C, Chicken broth. A clear liquid diet includes clear fluids and foods that are liquid at room temperature. Chicken broth is allowed on a clear liquid diet as it is a clear liquid, while tomato soup, apple juice, and cranberry juice are not clear liquids. Tomato soup is a thicker substance and not allowed on a clear liquid diet. Apple juice and cranberry juice are also not clear liquids because they contain pulp and are not transparent like broth.

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