a nurse is preparing to administer an intermittent enteral feeding to a client who has an ng tube which of the following actions should the nurse take
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Nursing Elites

ATI RN

ATI Exit Exam

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

Correct answer: D

Rationale: Verifying the pH of the gastric aspirate is the correct action to take before administering an intermittent enteral feeding through an NG tube. This step ensures proper tube placement in the stomach, as the gastric aspirate should have an acidic pH (usually below 5). Heating the feeding solution, elevating the head of the bed, or flushing the tube with saline are not directly related to verifying tube placement and are not the immediate actions needed before administering the feeding.

2. A client is postoperative following a thyroidectomy. Which of the following findings should the nurse identify as an indication of hypocalcemia?

Correct answer: B

Rationale: Numbness and tingling of the fingers are classic signs of hypocalcemia, a condition that may result from inadvertent damage to the parathyroid glands during a thyroidectomy. These symptoms occur due to decreased levels of calcium in the bloodstream affecting nerve function. Choices A, C, and D are not typical manifestations of hypocalcemia. Constipation is more associated with hypercalcemia, increased thirst can be seen in diabetes or dehydration, and frequent urination is a symptom more commonly linked to conditions like diabetes or urinary tract issues.

3. A client is experiencing a panic attack. Which of the following actions should the nurse take first?

Correct answer: C

Rationale: During a panic attack, the priority action for the nurse is to remain with the client and offer reassurance. This helps provide a sense of safety and security, which can aid in reducing the client's anxiety. Instructing the client to take deep, slow breaths (Choice A) can be beneficial but should come after providing immediate support. Administering medication (Choice B) should not be the first intervention unless deemed necessary by the healthcare provider. Encouraging distraction techniques (Choice D) may not be as effective initially as providing direct support and reassurance.

4. A client at risk for osteoporosis is receiving teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B: 'I should increase my intake of vitamin D.' Adequate vitamin D intake is crucial for calcium absorption, which is essential for bone health and preventing osteoporosis. Avoiding weight-bearing exercises (choice A) would be detrimental as weight-bearing activities help improve bone density. Reducing dairy intake (choice C) is not recommended as dairy products are a good source of calcium. While increasing calcium intake (choice D) is important, ensuring sufficient vitamin D levels for proper absorption is equally crucial for bone health.

5. A patient is receiving radiation therapy. Which of the following skin care instructions should the nurse provide?

Correct answer: D

Rationale: Correct Answer: The nurse should instruct the patient to wear loose clothing over the radiation site. This helps prevent skin irritation and promotes healing by reducing friction and irritation on the treated area.\nChoice A is incorrect because applying a heating pad can further irritate the skin that is already sensitive due to radiation therapy.\nChoice B is incorrect because scented lotions may contain ingredients that could further irritate the skin.\nChoice C is incorrect because covering the radiation site with a bandage can trap moisture and lead to skin breakdown, increasing the risk of infection.

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