an intubated patient is receiving continuous enteral feedings through a salem sump tube at a rate of 60mlhr gastric residuals have been 30 40ml when m an intubated patient is receiving continuous enteral feedings through a salem sump tube at a rate of 60mlhr gastric residuals have been 30 40ml when m
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Nursing Elites

ATI RN

ATI Gastrointestinal System Test

1. An intubated patient is receiving continuous enteral feedings through a Salem sump tube at a rate of 60ml/hr. Gastric residuals have been 30-40ml when monitored Q4H. You check the gastric residual and aspirate 220ml. What is your first response to this finding?

Correct answer: B

Rationale: If gastric residuals are high during continuous enteral feedings, the first response is to stop the feeding and clamp the NG tube.

2. A healthcare provider assesses a client with pneumonia. Which clinical manifestation should the provider expect to find?

Correct answer: C

Rationale: Pneumonia often leads to the consolidation of lung tissue, resulting in dullness on percussion. This occurs due to the presence of fluid or inflammatory material in the alveoli. Fremitus and decreased tactile fremitus are more indicative of conditions like pleural effusion or pneumothorax, where there is an increase in the density of the pleural space or air in the pleural cavity. Hyperresonance, on the other hand, is typically associated with conditions causing air trapping, such as emphysema, where there is increased air in the alveoli.

3. When caring for a patient with a nasogastric (NG) tube, what is the most appropriate intervention to prevent aspiration?

Correct answer: C

Rationale: Elevating the head of the bed to 30-45 degrees is the most appropriate intervention to prevent aspiration in a patient with an NG tube. This position helps reduce the risk of regurgitation and aspiration by promoting the proper flow of contents through the gastrointestinal tract and minimizing the chances of stomach contents entering the airway. Flushing the NG tube with water before each feeding may not directly prevent aspiration. Checking the placement of the NG tube is important but does not specifically address the prevention of aspiration. Providing oral care every 4 hours is essential for maintaining oral hygiene but is not directly related to preventing aspiration in a patient with an NG tube.

4. A client with stomatitis is receiving teaching from a nurse. Which of the following client statements indicates a need for further teaching?

Correct answer: “I will rinse my mouth with baking soda and water frequently.”

Rationale: The correct answer is, “I will rinse my mouth with baking soda and water frequently.” Stomatitis is an inflammation of the mucous lining in the mouth, and rinsing with baking soda and water can be too abrasive and further irritate the condition. Choices A, B, and D are appropriate self-care measures for a client with stomatitis and do not indicate a need for further teaching.

5. Testosterone production is regulated by which of the following glands?

Correct answer: D

Rationale: Testosterone production is regulated by the pituitary gland. The pituitary gland secretes luteinizing hormone (LH), which stimulates the Leydig cells in the testes to produce testosterone. This hormone is not regulated by the Pineal, Thymus, or Parathyroid glands. The Pineal gland is responsible for secreting melatonin, the Thymus gland is involved in immune function, and the Parathyroid glands regulate calcium levels in the blood.

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