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

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?

A. Notify the doctor immediately.
B. Stop the feeding, and clamp the NG tube.
C. Discard the 220ml, and clamp the NG tube.
D. Give a prescribed GI stimulant such as metoclopramide (Reglan).

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. Glenda has cholelithiasis (gallstones). You expect her to complain of:

A. Pain in the right upper quadrant, radiating to the shoulder.
B. Pain in the right lower quadrant, with rebound tenderness.
C. Pain in the left upper quadrant, with shortness of breath.
D. Pain in the left lower quadrant, with mild cramping.

Correct answer: A

Rationale: Patients with cholelithiasis often complain of pain in the right upper quadrant, radiating to the shoulder.

3. The student nurse is teaching the family of a patient with liver failure. You instruct them to limit which foods in the patientâ€™s diet?

A. Meats and beans.
B. Butter and gravies.
C. Potatoes and pastas.
D. Cakes and pastries.

Correct answer: A

Rationale: For a patient with liver failure, it is important to limit the intake of meats and beans to reduce the risk of hepatic encephalopathy.

4. The client with chronic pancreatitis needs information on dietary modification to manage the health problem. The nurse teaches the client to limit which of the following items in the diet?

A. Carbohydrate
B. Protein
C. Fat
D. Water-soluble vitamins

Correct answer: C

Rationale: The client should limit fat in the diet. The client also should take in small meals, which also will reduce the amount of carbohydrates and protein that the client must digest at any one time. The client does not need to limit water-soluble vitamins in the diet.