ATI LPN
ATI PN Adult Medical Surgical 2019
1. The client has a nasogastric (NG) tube and is receiving enteral feedings. What intervention should the nurse implement to prevent complications associated with the NG tube?
- A. Flush the NG tube with water before and after feedings.
- B. Check gastric residual volume every 6 hours.
- C. Keep the head of the bed elevated at 30 degrees.
- D. Replace the NG tube every 24 hours.
Correct answer: C
Rationale: Keeping the head of the bed elevated at 30 degrees is crucial in preventing aspiration, a common complication associated with nasogastric (NG) tubes and enteral feedings. This position helps reduce the risk of reflux and aspiration of gastric contents into the lungs, promoting client safety and preventing respiratory complications. Flushing the NG tube with water before and after feedings (Choice A) is not the primary intervention to prevent complications. Checking gastric residual volume every 6 hours (Choice B) is important but not directly related to preventing complications associated with the NG tube. Replacing the NG tube every 24 hours (Choice D) is not a standard practice and is not necessary to prevent complications if the tube is functioning properly.
2. A patient with coronary artery disease (CAD) is prescribed a statin medication. What should the nurse include in the patient education?
- A. Take the medication with food.
- B. Report any muscle pain or weakness.
- C. Increase intake of grapefruit juice.
- D. Avoid foods high in potassium.
Correct answer: B
Rationale: Patients prescribed statin medications should be educated to report any muscle pain or weakness to their healthcare provider promptly. Muscle pain or weakness could be a sign of rhabdomyolysis, a serious side effect associated with statin use that requires medical attention. Choices A, C, and D are incorrect. Taking statins with food or increasing grapefruit juice intake are not necessary recommendations. Avoiding foods high in potassium is also not directly related to statin use.
3. When should the charge nurse intervene based on the observed behavior?
- A. Two staff members are overheard talking about a cure for AIDS outside a client's room.
- B. A hospital transporter is reading a client's history and physical while waiting for an elevator.
- C. A UAP tells a client, 'It's hard to quit drinking but Alcoholics Anonymous helped me.'
- D. Two visitors are discussing a hospitalized client's history of drug abuse in the visitor's lounge.
Correct answer: B
Rationale: The hospital transporter reading a client's history and physical without a legitimate need violates patient confidentiality. This behavior requires immediate intervention to protect the client's privacy and confidentiality rights.
4. What health promotion teaching should prioritize to prevent drug-induced hepatitis?
- A. Finish all prescribed courses of antibiotics, regardless of symptom resolution
- B. Adhere to dosing recommendations of over-the-counter analgesics
- C. Ensure that expired medications are disposed of safely
- D. Ensure that pharmacists regularly review drug regimens for potential interactions
Correct answer: B
Rationale: Adhering to dosing recommendations of over-the-counter analgesics is crucial in preventing drug-induced hepatitis. Overdosing on analgesics can lead to liver damage, making it essential to follow the recommended dosages to reduce the risk of hepatotoxicity.
5. A client with a history of hypertension is prescribed lisinopril (Prinivil). Which side effect should the nurse monitor for?
- A. Dry cough.
- B. Weight gain.
- C. Tachycardia.
- D. Hyperglycemia.
Correct answer: A
Rationale: The correct answer is A: Dry cough. Lisinopril is an ACE inhibitor, and a common side effect of ACE inhibitors is a dry cough. This occurs due to the accumulation of bradykinin in the lungs, leading to irritation and subsequent cough. It is important for the nurse to monitor the client for this side effect as it can affect adherence to the medication regimen. Weight gain, tachycardia, and hyperglycemia are not typically associated with lisinopril. Therefore, choices B, C, and D are incorrect.
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