ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 60 Questions
Question 1 of 5
A client is receiving continuous tube feeding at 70 mL/hr. When the bag is empty, how much formula does the nurse add? (Record your answer using a whole number.) mL
Correct Answer: A
Rationale: The nurse never adds more than 4 hours' worth of formula to a hanging bag of enteral feedings: 70 mL/hr ? 4 hr = 280 mL.
Question 2 of 5
A client is receiving total parenteral nutrition (TPN). On assessment, the nurse notes the client's pulse is 128 beats/min, blood pressure is 90/56 mm Hg, and skin turgor is dry. What action should the nurse perform next?
Correct Answer: A
Rationale: The client has clinical indicators of dehydration, so the nurse calculates the client's 24-hour intake, output, and fluid balance. This information is then reported to the provider. Assessing the oral cavity may or may not be consistent with dehydration. A fluid bolus may be needed, but not as an independent action. Notifying the provider is appropriate after data collection.
Question 3 of 5
A client having a tube feeding begins vomiting. What action by the nurse is most appropriate?
Correct Answer: C
Rationale: The nurse should hold the feeding until the nausea and vomiting have subsided and consult with the provider on the rate at which to restart the feeding. Giving an antiemetic is not appropriate without a provider's order. Checking gastric residual is important but not while the client is vomiting. Continuing to feed the client during vomiting is unsafe.
Question 4 of 5
A client tells the nurse about losing weight and regaining it multiple times. Besides eating and exercising habits, what should the nurse assess as the priority?
Correct Answer: C
Rationale: Psychosocial influences, such as stress, emotional eating, or social pressures, can significantly impact weight management and should be assessed as a priority to provide holistic care. Economic ability, food allergies, and reasons for weight loss are important but secondary.
Question 5 of 5
A nurse is caring for four clients receiving enteral tube feedings. Which client should the nurse see first?
Correct Answer: C
Rationale: The potassium level of 2.6 mEq/L is critically low, possibly due to hyperglycemia-induced hyperosmolality. The nurse should see this client first. The blood glucose reading is high but not extreme. The sodium level is normal. The client with diarrhea should be seen last to avoid cross-contamination.