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)
- A. The nursing assistant aspirates and measures the amount of the gastric aspirate
- B. The nursing assistant elevates the head of the client’s bed 30 degrees
- C. The nursing assistant warms the formula to room temperature
- D. B, C
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. A two-month-old infant who has gastroesophageal reflux is thriving without other complications. Which instruction should the nurse include in the teaching plan?
- A. Place the infant in the Trendelenburg position after feeding
- B. Thicken formula with rice cereal
- C. Give continuous nasogastric feedings
- D. Give larger, less frequent feeds
Correct answer: B
Rationale: The correct instruction for a two-month-old infant with gastroesophageal reflux who is thriving without complications is to thicken the formula with rice cereal. This can help reduce reflux by increasing the weight of the formula, making it less likely to be regurgitated. Placing the infant in the Trendelenburg position after feeding (Choice A) is not recommended as it can increase the risk of aspiration. Continuous nasogastric feedings (Choice C) are not typically indicated for uncomplicated reflux in infants. Giving larger, less frequent feeds (Choice D) can worsen reflux symptoms by overloading the stomach.
3. Why is the administration of benzene hexachloride (Lindane) for the treatment of scabies applied in small quantities?
- A. Excessive applications will lead to central nervous system toxicity.
- B. Excessive applications will cause irritation, rash, and inflammation.
- C. Excessive applications will cause headaches, dizziness, and diarrhea.
- D. Excessive applications will lead to anorexia and cachexia.
Correct answer: A
Rationale: The rationale for instructing the patient to apply benzene hexachloride (Lindane) in small quantities for scabies treatment is that excessive applications can lead to central nervous system toxicity. Lindane is a neurotoxin, and overuse or incorrect application can result in adverse effects on the central nervous system, such as seizures, dizziness, and even death. Choices B, C, and D are incorrect because they do not reflect the specific toxic effects associated with Lindane, which primarily affects the central nervous system rather than causing skin irritation, gastrointestinal symptoms, or metabolic issues.
4. A dietitian tells you that you are not consuming enough calories. Which of the following nutrients could you add to your diet to increase your energy intake?
- A. fiber
- B. water
- C. protein
- D. vitamins
Correct answer: C
Rationale: Corrected Rationale: Protein provides 4 kcal per gram, making it a good source of energy to increase caloric intake. While fiber and water are important for other aspects of health, they do not provide energy like protein does. Vitamins are essential for various bodily functions but do not contribute directly to caloric intake.
5. A client with schizophrenia is experiencing auditory hallucinations. Which nursing intervention is most appropriate to address this symptom?
- A. Encourage the client to discuss the voices.
- B. Instruct the client to listen to music to drown out the voices.
- C. Tell the client that the voices are not real.
- D. Distract the client from the voices.
Correct answer: A
Rationale: Encouraging the client to discuss the voices is the most appropriate nursing intervention when a client with schizophrenia is experiencing auditory hallucinations. By discussing the voices, the client can feel heard, understood, and supported. It allows the client to express their experiences, which can help in processing and coping with the hallucinations. This intervention promotes therapeutic communication and builds a trusting nurse-client relationship, which is essential in providing effective care for individuals with schizophrenia. Choice B is incorrect because instructing the client to listen to music to drown out the voices does not address the underlying issue and may not be effective in managing auditory hallucinations. Choice C is incorrect because telling the client that the voices are not real can invalidate the client's experiences and feelings, leading to further distress. Choice D is incorrect as solely distracting the client from the voices does not help in addressing the hallucinations or supporting the client in dealing with their symptoms.