a nurse is providing teaching about the gastrostomy tube feedings to the parents of a school age child which of the following instructions should the

ATI RN

ATI Comprehensive Exit Exam 2023 With NGN Quizlet

1. A nurse is providing teaching about gastrostomy tube feedings to the parents of a school-age child. Which of the following instructions should the nurse give?

A. Administer the feeding over 30 minutes
B. Place the child in a supine position after the feeding
C. Change the feeding bag and tubing every 3 days
D. Warm the formula in the microwave prior to administration

Correct answer: A

Rationale: The correct answer is to administer the feeding over 30 minutes. This slow administration helps prevent complications like nausea. Placing the child in a supine position after the feeding can increase the risk of aspiration, making choice B incorrect. Changing the feeding bag and tubing every 3 days is important for infection control and hygiene but is not directly related to the administration process, making choice C incorrect. Warming the formula in the microwave is not recommended as it can create hot spots that may burn the child's mouth or esophagus, so choice D is incorrect.

2. What is the best position for a patient with respiratory distress?

A. Semi-Fowler's position
B. Trendelenburg position
C. Prone position
D. Supine position

Correct answer: A

Rationale: The best position for a patient with respiratory distress is the Semi-Fowler's position. This position promotes lung expansion and improves oxygenation by allowing the chest to expand more fully. The Trendelenburg position, where the patient's feet are higher than the head, is contraindicated in respiratory distress as it can increase pressure on the diaphragm and compromise breathing. The prone position, lying face down, may be beneficial in certain cases like acute respiratory distress syndrome but is not generally recommended for all patients in respiratory distress. The supine position, lying flat on the back, can worsen respiratory distress by causing the tongue to fall back and obstruct the airway.

3. A nurse is reviewing the laboratory results of a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse report to the provider?

A. White blood cell count 6,000/mm3
B. Positive antinuclear antibody (ANA) titer
C. Platelet count 220,000/mm3
D. Blood urea nitrogen (BUN) 15 mg/dL

Correct answer: B

Rationale: A positive antinuclear antibody (ANA) titer is a significant finding in clients with systemic lupus erythematosus (SLE) as it indicates active disease. This result should be reported to the provider for further evaluation and management. Choices A, C, and D are within normal ranges and not specifically indicative of disease activity in SLE. Therefore, they do not require immediate reporting to the provider.

4. A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse take?

A. Massage the injection site after administration.
B. Administer the medication intramuscularly.
C. Inject the medication into the client's abdomen.
D. Inject the medication into the deltoid muscle.

Correct answer: C

Rationale: The correct answer is to inject the medication into the client's abdomen. Enoxaparin is a medication that should be administered subcutaneously, not intramuscularly. Massaging the injection site after administration is not recommended as it can cause bruising or discomfort. Injecting the medication into the deltoid muscle is also incorrect because enoxaparin should be given in areas of adipose tissue, such as the abdomen, to ensure proper absorption and effectiveness.

5. What is the best position for a patient experiencing shortness of breath?

A. Supine position
B. Semi-Fowler's position
C. Trendelenburg position
D. Prone position

Correct answer: B

Rationale: The best position for a patient experiencing shortness of breath is the Semi-Fowler's position. This position promotes lung expansion and improves oxygenation by allowing the chest to expand more fully. The Supine position (lying flat on the back) may worsen breathing difficulties by reducing lung capacity. The Trendelenburg position (feet elevated higher than the head) is not recommended for patients with shortness of breath as it can increase pressure on the diaphragm and compromise breathing. The Prone position (lying face down) is also not suitable for patients experiencing shortness of breath as it may further restrict breathing.