a nurse is preparing to administer an intermittent enteral feeding to a client who has a gastrostomy tube which of the following actions should the nu
Logo

Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023

1. A nurse is preparing to administer an intermittent enteral feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take?

Correct answer: B

Rationale: Administering an intermittent enteral feeding through a gastrostomy tube requires flushing the tube with 10 mL of sterile water before feeding. This action helps ensure patency and prevents clogging. Choice A is incorrect because flushing after feeding does not address the need for pre-feeding tube flushing. Choice C is unrelated to tube feeding administration. Choice D is incorrect as the height of the feeding bag above the abdomen is typically regulated by healthcare facility policies and is not a universal standard.

2. Which of the following lab values should the nurse monitor for a patient receiving heparin therapy?

Correct answer: C

Rationale: The correct answer is to monitor aPTT for a patient receiving heparin therapy. The activated partial thromboplastin time (aPTT) is used to assess and adjust heparin dosage to ensure the patient is within the therapeutic range for anticoagulation. Monitoring the aPTT helps in preventing both clotting and bleeding complications. Platelet count (Choice A) is important to monitor for patients receiving antiplatelet therapy, not heparin. PT/INR (Choice B) is typically monitored for patients on warfarin therapy, not heparin. Monitoring the complete blood count (CBC) (Choice D) is essential for various conditions but is not specific to monitoring heparin therapy.

3. A nurse is caring for a client who has a urinary tract infection (UTI) and is prescribed ciprofloxacin. The nurse should instruct the client to monitor for and report which of the following adverse effects?

Correct answer: B

Rationale: The correct answer is B: Photosensitivity. Ciprofloxacin, an antibiotic commonly used to treat UTIs, can cause photosensitivity as an adverse effect. This reaction makes the skin more sensitive to sunlight, potentially leading to severe sunburns or skin damage. It is crucial for the client to be aware of this adverse effect to take precautions and report any signs of photosensitivity promptly. Choices A, C, and D are incorrect because tinnitus, urinary frequency, and insomnia are not typically associated with ciprofloxacin use. While urinary frequency might be a symptom of UTI, it is not an adverse effect of the medication itself.

4. A client has Clostridium difficile infection. Which of the following actions should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client with Clostridium difficile infection is to place the client on contact precautions. This helps prevent the spread of the infection to other clients. Washing hands with an alcohol-based hand rub is important for infection control but is not specific to preventing the spread of Clostridium difficile. Wearing a mask may be necessary for airborne precautions but is not the priority for Clostridium difficile infection. Double-bagging linens is not a standard practice for preventing the spread of Clostridium difficile.

5. A nurse is assessing a school-age child who has a urinary tract infection (UTI). Which of the following findings should the nurse expect?

Correct answer: C

Rationale: Enuresis is the correct finding to expect in a school-age child with a urinary tract infection. Enuresis, or involuntary urination, is a common symptom of UTIs in children. Periorbital edema (Choice A) is not typically associated with UTIs. Decreased frequency of urination (Choice B) is less likely in UTIs as there is often an increased urge to urinate. Diarrhea (Choice D) is not a common symptom of UTIs and is more indicative of gastrointestinal issues.

Similar Questions

A nurse is caring for a client who has deep-vein thrombosis (DVT) and is receiving heparin therapy. Which of the following laboratory values indicates that the client's heparin therapy is effective?
A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect?
A nurse is reviewing the laboratory results of a client who is at 28 weeks of gestation. Which of the following laboratory values should the nurse report to the provider?
What is the most important nursing intervention for a patient experiencing an acute asthma attack?
A nurse is caring for a client who has a pneumothorax and is being treated with a chest tube. Which of the following findings indicates that the lung has re-expanded?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses