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. A nurse is caring for a 1-day-old newborn who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take?

Correct answer: C

Rationale: The correct action for the nurse to take is to ensure that the newborn wears a diaper. This is important to prevent irritation during phototherapy, as exposure to light can increase the risk of skin breakdown. Feeding the infant glucose water is unnecessary and not indicated for jaundice treatment. Keeping the infant's head uncovered allows the light to reach the skin effectively. Applying lotion to the newborn every 4 hours can interfere with the effectiveness of phototherapy and is not recommended.

3. A nurse is reviewing the medical record of a client who has a new prescription for spironolactone. Which of the following findings should the nurse report to the provider?

Correct answer: D

Rationale: A serum creatinine level of 3.0 mg/dL indicates impaired kidney function, which is a concern when prescribing spironolactone as it can further affect renal function. Elevated serum creatinine levels may suggest decreased renal clearance of spironolactone, leading to potential toxicity. Potassium, calcium, and magnesium levels are within normal ranges and not directly related to spironolactone therapy. Therefore, the nurse should report the elevated serum creatinine level to the provider for further evaluation and possible dosage adjustment.

4. A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse is to insert the catheter until urine flow is established. This helps ensure proper placement and reduces the risk of trauma. Choice A (7.5 cm) and Choice D (5 cm) provide specific measurements that may not be appropriate for all individuals as catheter insertion depth can vary. Choice C is incorrect as catheters should be cleansed with an appropriate solution such as sterile saline, not sterile water.

5. A nurse is providing care for a client who is in the advanced stage of amyotrophic lateral sclerosis (ALS). Which of the following referrals is the nurse's priority?

Correct answer: D

Rationale: In the advanced stage of ALS, clients often experience swallowing difficulties, known as dysphagia. A speech-language pathologist specializes in assessing and managing these swallowing problems, making them the nurse's priority referral in this case. A psychologist primarily focuses on mental health and emotional well-being, which may not be the most critical issue at this stage. Social workers assist with social support and resources, while occupational therapists help with activities of daily living and mobility, which are important but not the priority when dysphagia is a concern.

Similar Questions

A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian.
A nurse is planning care for a client who has a closed head injury and has an intraventricular catheter. Which of the following interventions should the nurse include to reduce the risk for infection?
A healthcare provider is reviewing laboratory results for a client who is receiving heparin therapy. Which of the following results indicates that the medication is effective?
A nurse is assessing a client who has hypovolemia. Which of the following findings should the nurse expect?
A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following findings should the nurse report to the provider?

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