a nurse is preparing to administer enteral feedings to a client with a nasogastric ng tube what action should the nurse take first
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Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. A nurse is preparing to administer enteral feedings to a client with a nasogastric (NG) tube. What action should the nurse take first?

Correct answer: B

Rationale: Verifying tube placement is the crucial initial step a nurse should take before administering enteral feedings through an NG tube. This step ensures that the tube is correctly positioned in the stomach, reducing the risk of complications such as aspiration. Measuring residual gastric volume, flushing the tube with water, or administering the feeding in small boluses are all important steps in enteral feeding but should only be done after confirming the correct tube placement.

2. A client is found on the floor experiencing a seizure. What is the nurse's priority action?

Correct answer: B

Rationale: The nurse's priority action when finding a client experiencing a seizure is to place the client on their side. This action helps maintain an open airway and prevents aspiration, which is crucial during a seizure. Applying oxygen may be necessary after ensuring a patent airway, while administering an anticonvulsant is not within the nurse's scope of practice during an acute seizure. Notifying the provider can be done after ensuring the client's immediate safety.

3. A nurse is completing an admission assessment for a client who has hearing loss. What action should the nurse take?

Correct answer: A

Rationale: Using written communication is the most effective action for a nurse when assessing a client with hearing loss. This method helps overcome communication barriers by providing information visually, ensuring the client understands the assessment questions and instructions. Speaking louder (choice B) may distort the sound and not necessarily improve understanding. Facing the client (choice C) is important for lip reading but may not be sufficient for effective communication. Providing care in a quiet environment (choice D) is beneficial but might not fully address the need for clear communication in the assessment process for a client with hearing loss.

4. A nurse is caring for a client who has a prescription for a narcotic medication. After administration, what should the nurse do with the unused portion?

Correct answer: C

Rationale: After administering a narcotic medication, any unused portion should be discarded with another nurse as a witness. This procedure ensures proper disposal of controlled substances and prevents misuse or diversion. Storing it for later use (Choice B) is not appropriate due to safety concerns and legal regulations. Returning it to the pharmacy (Choice D) is also not recommended as the medication is already out of the pharmacy's control. Documenting the amount wasted (Choice A) is important for accurate record-keeping but does not address the immediate need for safe disposal of the unused narcotic medication.

5. A client with diabetes mellitus is being taught about foot care by a nurse. Which instruction should the nurse include?

Correct answer: B

Rationale: The correct answer is to 'Wear shoes at all times.' This instruction is crucial for preventing foot injuries in clients with diabetes mellitus. Wearing shoes protects the feet from potential injuries and reduces the risk of developing foot ulcers. Cutting toenails straight across (not in a rounded shape) helps prevent ingrown toenails. Applying lotion between the toes can create a moist environment, increasing the risk of fungal infections. Soaking feet in hot water daily can lead to dry skin and potentially cause burns, which is not recommended for individuals with diabetes.

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