a patient who received an enema reports abdominal cramping what should the nurse do a patient who received an enema reports abdominal cramping what should the nurse do
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Nursing Elites

ATI RN

ATI Capstone Medical Surgical Assessment 1 Quizlet

1. A patient who received an enema reports abdominal cramping. What should the nurse do?

Correct answer: B

Rationale: When a patient who received an enema reports abdominal cramping, the nurse should lower the height of the enema solution container. This adjustment can help reduce the cramping by slowing down the flow of the solution into the colon, allowing the patient to tolerate the procedure better. Increasing the flow of the solution (Choice A) can exacerbate the cramping. Removing the enema tubing (Choice C) or stopping the procedure (Choice D) may not address the issue and could lead to incomplete treatment.

2. At what age range is it important to feed a baby in a more upright position and no longer in sidelying?

Correct answer: B

Rationale: Feeding a baby in a more upright position and no longer in sidelying is important around 4-6 months of age. At this stage, babies start developing better head and trunk control, which allows them to sit in a more upright position for feeding, promoting safer and more efficient swallowing and digestion. Choices A, C, and D are incorrect as feeding a baby in a more upright position typically starts around 4-6 months when the baby has gained more control over their head and trunk movements, making it safer and more effective for feeding.

3. What is the purpose of the cuff in a Tracheostomy tube?

Correct answer: B

Rationale: The purpose of the cuff in a Tracheostomy tube is to separate the trachea from the esophagus. The cuff helps prevent aspiration by creating a seal that separates the trachea from the esophagus, reducing the risk of food or fluids entering the lungs. Choices A, C, and D are incorrect because the cuff's primary function in a Tracheostomy tube is to prevent aspiration rather than separating the upper and lower airway, larynx from the nasopharynx, or securing the placement of the tube.

4. During the later stages of chronic kidney disease, what is the recommended protein intake in grams per kilogram of body weight per day?

Correct answer: A

Rationale: In the later stages of chronic kidney disease, the recommended protein intake is typically restricted to 0.6 to 0.75 grams per kilogram of body weight per day. This lower protein intake helps reduce the workload on the kidneys, as excessive protein can be challenging for the kidneys to process. Choice B (1.2 to 1.55) is incorrect as it suggests a higher protein intake, which is not recommended for individuals with advanced kidney disease. Choices C (1.0 to 1.2) and D (0.8 to 1.0) also advocate for protein intakes higher than what is typically advised for individuals in later stages of chronic kidney disease.

5. While auditing care plans for clients with eating disorders, the nurse realizes that a nursing diagnosis appropriate for a client with anorexia nervosa as well as for a client with bulimia nervosa is

Correct answer: Chronic low self-esteem

Rationale: Chronic low self-esteem is a nursing diagnosis that can be applicable to clients with both anorexia nervosa and bulimia nervosa. These eating disorders are often associated with distorted body image, feelings of inadequacy, and low self-esteem. Clients with these conditions may engage in harmful behaviors related to their self-image, making chronic low self-esteem a relevant nursing diagnosis for them.

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