the nurse supervises care of a client who is receiving enteral feeding via a nasogastric tube the nurse determines that care is appropriate if which o
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Nursing Elites

ATI RN

ATI RN Custom Exams Set 3

1. The nurse supervises care of a client who is receiving enteral feeding via a nasogastric tube. The nurse determines that care is appropriate if which of the following is observed? (Select all that apply)

Correct answer: D

Rationale: Elevating the head of the bed to 30 degrees reduces the risk of aspiration by promoting proper digestion and preventing reflux. Warming the formula to room temperature is essential to prevent discomfort and complications. Aspirating and measuring the gastric aspirate is not a recommended nursing action for monitoring enteral feeding via a nasogastric tube, as it can introduce the risk of introducing contaminants into the feeding tube. Therefore, choices A and B are incorrect, making choice D the correct answer.

2. Interacting with the patient and their family to obtain subjective information is part of which of the following steps in determining and fulfilling the nursing care needs of the patient?

Correct answer: D

Rationale: The correct answer is D, Assessment. In the nursing process, assessment is the first step where nurses gather subjective and objective data to understand the patient's needs. Interacting with the patient and their family to obtain subjective information is crucial in this phase. Choice A, Evaluation, comes later in the process and involves judging the effectiveness of the care provided. Choice B, Planning, is where the nurse develops a plan of care based on the assessment findings. Choice C, Implementation, is the phase where the nursing care plan is put into action.

3. The nurse is teaching the client with peripheral vascular disease. Which intervention should the nurse discuss with the client?

Correct answer: D

Rationale: The correct interventions for a client with peripheral vascular disease include keeping the area between the toes dry to prevent moisture-related skin issues and wearing comfortable, well-fitting shoes to prevent injury and promote circulation. Cutting toenails straight across is important to prevent ingrown toenails, but in this case, an arch cut can lead to injury. Therefore, choices A and B are correct, making option D the most appropriate answer. Choice C is incorrect in this context.

4. The nurse is caring for a client in a sickle cell crisis. Which is the pain regimen of choice to relieve the pain?

Correct answer: D

Rationale: Morphine is the preferred analgesic in sickle cell crisis due to its potency and effectiveness in managing severe pain.

5. Which intervention should the nurse implement for the client who has an ileal conduit?

Correct answer: C

Rationale: The correct intervention for a client with an ileal conduit is to report to the healthcare provider any decrease in urinary output. A decrease in urinary output can be indicative of a blockage or other complication, necessitating immediate attention. Choice A is incorrect because pouching the stoma with a margin around it is not directly related to managing complications. Choice B is incorrect as referring the client to an ostomy association may be beneficial for education but is not the immediate action needed for decreased urinary output. Choice D is incorrect because monitoring for infection, although important, is not the priority when dealing with a potential complication like decreased urinary output.

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