ATI LPN
ATI PN Comprehensive Predictor 2023 Quizlet
1. What are the key nursing assessments for a patient receiving enteral feeding?
- A. Monitor gastric residual volume and check for abdominal distension
- B. Ensure the correct placement of the feeding tube
- C. Assess for signs of dehydration and electrolyte imbalances
- D. Elevate the head of the bed to prevent aspiration
Correct answer: A
Rationale: The correct answer is A: Monitor gastric residual volume and check for abdominal distension. These assessments are critical to evaluate the patient's tolerance to enteral feeding. Monitoring gastric residual volume helps determine gastric emptying, while checking for abdominal distension can identify complications like bowel obstruction. Choices B, C, and D are important aspects of enteral feeding care but are not the primary assessments. Ensuring the correct placement of the feeding tube is crucial for safety, assessing for signs of dehydration and electrolyte imbalances is essential for overall patient well-being, and elevating the head of the bed is vital to prevent aspiration. However, these are not the key assessments specifically related to enteral feeding.
2. Which hormone stimulates the gallbladder to contract?
- A. Secretin.
- B. Cholecystokinin (CCK).
- C. Gastrin.
- D. Gastric inhibitory polypeptide (GIP).
Correct answer: B
Rationale: Cholecystokinin (CCK) is the hormone responsible for stimulating the gallbladder to contract and release bile into the small intestine. Secretin primarily acts on the pancreas to stimulate the secretion of bicarbonate-rich fluid. Gastrin functions in the stimulation of gastric acid secretion, while Gastric inhibitory polypeptide (GIP) plays a role in inhibiting gastric acid secretion and stimulating insulin release.
3. A patient with obsessive-compulsive disorder (OCD) spends hours washing their hands. Which nursing intervention is most appropriate?
- A. Encouraging the patient to stop washing their hands
- B. Allowing the patient to wash hands at specified times
- C. Ignoring the patient's behavior
- D. Setting strict limits on the time allowed for hand washing
Correct answer: B
Rationale: In managing a patient with OCD who spends excessive time washing hands, allowing the patient to wash hands at specified times is the most appropriate nursing intervention. This approach helps establish a structured routine for hand washing, which can assist in managing OCD symptoms without reinforcing the behavior. Encouraging the patient to stop washing hands may lead to increased anxiety and resistance. Ignoring the behavior can perpetuate the cycle of OCD, and setting strict limits on hand washing time may cause distress and may not effectively address the underlying issues associated with OCD.
4. A nurse is teaching dietary guidelines to a client who has celiac disease. Which of the following food choices is appropriate for the client?
- A. White flour tortillas.
- B. Potato pancakes.
- C. Wheat crackers.
- D. Canned barley soup.
Correct answer: B
Rationale: The correct answer is B, potato pancakes. Individuals with celiac disease must avoid gluten-containing foods. Potato pancakes are gluten-free, making them a suitable choice for someone with celiac disease. Choice A, white flour tortillas, contains gluten from wheat flour, making it unsuitable for a client with celiac disease. Choice C, wheat crackers, also contain gluten and should be avoided. Choice D, canned barley soup, contains barley which is a gluten-containing grain and is not appropriate for someone with celiac disease.
5. An 18-month-old child presents with fever, nasal flaring, intercostal retractions, and a respiratory rate of 50 bpm. What is the most appropriate nursing diagnosis?
- A. High risk for altered body temperature - hyperthermia
- B. Ineffective breathing pattern
- C. Ineffective individual coping
- D. Knowledge deficit
Correct answer: B
Rationale: In this case, the child is showing signs of respiratory distress, such as nasal flaring, intercostal retractions, and an increased respiratory rate. These are indicative of an ineffective breathing pattern. The child's compromised respiratory function requires immediate attention and intervention, making 'Ineffective breathing pattern' the most appropriate nursing diagnosis. Choices A, C, and D do not address the respiratory distress the child is experiencing and are not the priority in this situation.
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