Unit 3 ATI Practice Questions
Elemental
ATIM: Enteral Feeding A nurse is caring for a client who has dysfunctional gastrointestinal tract and requires enteral feeding. Which of the following formulas should the nurse administer to the client? -modular -elemental -polymeric -specialty
480
ATIM: Nutrition A client has finished a 16 oz container of OJ. The intake and output sheet documents fluid in millimeters. What amount should the nurse document as the client's intake?
identify the food location as though the plate were a clock
ATIM: Nutrition Which of the following interventions should a nurse use at mealtimes for a client who has visual impairment? -identify the food location as though the plate were a clock -direct the order in which the food items are consumed -have the client tilt their head forward while eating -avoid talking to the client during their mealtime
to assess the pattern of intake and compare with daily reference intakes
ATIM: Nutrition Which of the following is the primary purpose for asking a client to keep a 3-7 day food diary? -to allow the client to relay on health professionals to identify problem areas -to determine any changes in the client's appetite -to evaluate any significant changes in body weight -to assess the pattern of intake and compare with daily reference intakes
making healthful food choices more convenient and available for the adolescent
ATIM: Nutrition Which of the following strategies for enhancing the intake of healthy foods is appropriate for an adolescent? -encouraging the adolescent to consume snack foods from the grains food group -permitting the adolescent to skip breakfast to enhance appetite at later meals -making healthful food choices more convenient and available for the adolescent -allowing the adolescent complete autonomy in making food choices
use irrigation to help establish a regular bowel pattern
ATIM: Ostomy Care A nurse is providing preoperative teaching for a client who is scheduled for creation of a sigmoid colostomy. Which of the following information should the nurse include in the teaching? -expect the effluent from the sigmoid colostomy to be loose and continuous -use irrigation to help establish a regular bowel pattern -change the stoma's appliance every other day -expect effluent from the newly created stoma within 24hr after surgery
push the skin away from the barrier while removing it
ATIM: Ostomy Care A nurse is reinforcing teaching with a client about replacing an ostomy pouching system. The client reports that they occasionally experience pain when removing the skin barrier. Which of the following techniques should the nurse suggest? -lift up on both sides of the skin barrier simultaneously -release one corner of the barrier and pull it quickly over the stoma -push the skin away from the barrier while removing it -gently roll the barrier end over end across the stoma
ileostomy
ATIM: Ostomy Care A nurse is reinforcing teaching with a client who has colon cancer and is scheduled for a procedure to remove their entire large intestine and rectum. The nurse should reinforce with the client that they are scheduled for which of the following types of ostomy procedure? -cecosotmy -loop colostomy -ileostomy -descending colostomy
cleanse the stoma and the peristomal skin
ATIM: Ostomy Care A nurse is replacing an ostomy appliance for a client whose newly created colostomy is functioning. After removing the pouch, which of the following actions should the nurse take first? -measure the stoma -cover the stoma with gauze -remove the backing on the skin barrier -cleanse the stoma and the peristomal skin
press gently around the barrier for 30seconds-1minute
ATIM: Ostomy Care A nurse is teaching a client about extended-wear skin barriers. Which of the following strategies should the nurse instruct the client to use for maximal adherence? -use an oil based lotion on the peristomal area -apply the skin barrier while the skin is slightly moist -leave the residue from the previous appliance on the skin -press gently around the barrier for 30seconds-1minute
verify tube placement with radiography when the pH value is greater than 6.5
A nurse is aspirating a client's secretions from an NG tube before administering the client's bolus enteral feeding. Which of the following actions should the nurse take? -reposition the feeding tube if aspirated secretions appear grassy green -verify tube placement with radiography when the pH value is greater than 6.5 -dispose of aspirated gastric contents -flush the feeding tube with 60 mL of water after aspirating gastric secretions
obtain a radiography
A nurse is inserting an NG tube for a client who is beginning enteral feedings. Which of the following actions should the nurse take to verify tube placement before administering the initial feeding? -auscultate for a whooshing sound when air is injected into the tube -check that the marked length of the tube is at the nares -perform a pH test on gastric secretions -obtain a radiography
allow 30 min for each feeding
A nurse is planning to administer intermittent enteral feedings for a client who has a gastrostomy tube. Which of the following actions should the nurse take? -dilute the initial enteral feeding with 100 mL of tap water -allow 30 min for each feeding -administer 550 mL of formula with each feeding -dispose of aspirated gastric residual volume prior to feeding
feedings through the NG tube can last 3-4 weeks
A nurse is teaching a client about the administration of enteral feedings through an NG tube. which of the following instructions should the nurse include in the teaching? -the tip of the NG tube will rest in the small bowel -feedings through the NG tube can last 3-4 weeks -a balloon located at the end of the NG tube maintains placement -removal of the NG tube occurs after each feeding
pH of 3.5
A nurse is testing the pH of gastric contents before administering a bolus enteral feeding for a client. Which of the following pH results should the nurse identify as gastric secretions? -pH of 8.5 -pH of 7.5 -pH of 3.5 -pH of 10
A, B, C
ATI Chapter 39: A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (Select all that apply) A: older adults are more prone to dehydration than younger adults B: older adults need the same amount of most vitamins and minerals as younger adults do C: many older men and women need calcium supplementation D: older adults need more calories they did when they were younger E: older adults should consume a diet low in carbohydrates
instruct the client to tuck their chin when swallowing
ATI Chapter 39: A nurse is caring for a client who is at high risk for aspiration. Which of the following actions should the nurse take? -give the client thin liquids -instruct the client to tuck their chin when swallowing -have client use a straw -encourage the client to lie down and rest after meals
vanilla custard
ATI Chapter 39: A nurse is caring for a client who requires a low residue diet. The nurse should expect to see which of the following foods on the client's meal tray? -cooked barley -pureed broccoli -vanilla custard -lentil soup
BMI = 31.25 (obese)
ATI Chapter 39: A nurse is caring for a client who weighs 80kg (176lg) and is 1.6m (5ft3in) tall. Calculate the body mass index (BMI) and determine whether the client's BMI indicates a healthy weight, underweight, overweight, or obese?
carbohydrates
ATI Chapter 39: A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most energy? -fat -protein -glycogen -carbohydrates
A, B, C
ATI Chapter 54: A nurse is caring for a client in a long term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? (select all that apply) A: auscultate bowel sounds B: assist the client to an upright position C: test the pH of gastric aspirate D: warm the formula to body temperature E: discard any residual gastric contents
stop the feeding
ATI Chapter 54: A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding? -auscultate breath sounds -stop the feeding -obtain a chest xray -initiate oxygen therapy
water helps clear the tube so it doesn't get clogged
ATI Chapter 54: A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains form the syringe, the client asks the nurse why the water is necessary. Which of the following responses should the nurse make? -water helps clear the tube so it doesn't get clogged -flushing helps make sure the tube stays in place -this will help you get enough fluids -adding water makes the formula less concentrated
A, B
ATI Chapter 54: A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure? (select all that apply) A: review a signal the client can use if feeling any distress B: lay a towel across the client's chest C: administer oral pain medication D: obtain a Dobhoff tube for insertion E: have a petroleum-based lubricant available
verify placement of the NG tube
ATI Chapter 54: A nurse is preparing to instill an enteral feeding for a client who has an NG tube in place. Which of the following actions is the nurse's highest assessment priority before performing this procedure? -check how long the feeding container has been opened -verify placement of the NG tube -confirm that the client does not have diarrhea -make sure the client is alert and oriented
return flow
ATIM: Bowel Elimination A client who is postoperative is experiencing abdominal distension and is having difficulty expelling flatus. The nurse should expect the provider to prescribe which of the following types of enemas? -cleansing -return flow -medicated -oil retention
lower the container to allow the solution to flow back out
ATIM: Bowel Elimination A nurse is administering a return-flow enema to a client. After instilling 100mL of enema fluid, which of the following actions should the nurse take? -instruct the client to retain the fluid -lower the container to allow the solution to flow back out -help the client to the toilet or bedside commode -wait 5 min and instill another 100mL of fluid
7.5cm to 10cm (3 to 4in)
ATIM: Bowel Elimination A nurse is administering an enema medicated with sodium polystyrene sulfonate to an adult client who has hyperkalemia. To which of the following lengths should the nurse insert the rectal tube? -2.5cm to 3.75cm (1 to 1.5in) -5cm to 7.5cm (2 to 3in) -7.5cm to 10cm (3 to 4in) -10cm to 12.5cm (4 to 5in)
left lateral with right knee flexed
ATIM: Bowel Elimination A nurse is preparing an adult client for an enema. The nurse should assist the client into which of the following positions? -prone -dorsal recumbent -right lateral with both knees flexed -left lateral with right knee flexed
place the client in the dorsal recumbent position on a bedpan
ATIM: Bowel Elimination A nurse is preparing to administer a cleansing enema to a client who has poor sphincter control. Which of the following actions should the nurse take? -place the client in the dorsal recumbent position on a bedpan -administer the enema while the client sits on the toilet -administer an antidiarrheal medication 3 hr prior to the enema -instill 200 mL of fluid over an hour at 15 min intervals
at least 30 min
ATIM: Bowel Elimination A nurse is preparing to administer an oil retention enema to a client who has constipation. The nurse should instruct the client to retain the solution for which of the following duration? -the duration of the procedure -10 to 15 min -until the client feels the urge to defecate -at least 30 min
warm the enema solution prior to instillation
ATIM: Bowel Elimination A nurse is preparing to administer the first of two large volume, cleansing enemas prescribed for a client in preparation for a diagnostic procedure. Which of the following actions should the nurse take? -warm the enema solution prior to instillation -prepare 1500mL of enema fluid -use tap water as the enema fluid -hang the enema container 24in above the anus
lower the enema fluid container
ATIM: Bowel Elimination While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? -measure the client's vital signs -notify the primary care provider -lower the enema fluid container -stop the enema instillation
encourage the client to go to the dining room at meal times to talk with other clients
ATIM: Enteral Feeding A client who lives in a long term care facility receiving intermittent enteral feedings and is experiencing social isolation. Which of the following interventions should the nurse recommend? -encourage the client to go to the dining room at meal times to talk with other clients -suggest that the client watch television while feedings are being administered -remind the client that they can have visitors after feeding administration times -ask the facility chaplain to speak with the client
place the client in fowlers position
ATIM: Enteral Feeding A nurse is administering an enteral feeding to a client. Which of the following actions should the nurse take to prevent aspiration? -flush the feeding tube with 30mL of water -add blue food coloring to the enteral formula -ensure the formula is at room temperature -place the client in fowlers position
nasointestinal tube
ATIM: Enteral Feeding A nurse is caring for a client who has a paralytic ileus and requires nutritional support for approximately 2 weeks. Which of the following types of feeding tubes should the nurse anticipate the provider to prescribe? -nasogastric tube -nasointestinal tube -percutaneous endoscopic gastrostomy tube -percutaneous endoscopic jejunostomy tube
A client who has dysphagia
ATIM: Enteral Feeding A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevention aspiration?
closing off the glottis
ATIM: Enteral Feeding A nurse is inserting a nasogastric tube for a client and asks the client to flex their head toward their chest after the tube passes through the nasopharynx. This action facilitates proper insertion of the tube by achieving which of the following? -closing off the glottis -preventing curling of the tube in the mouth -allowing the client to breathe through the mouth -opening the esophageal sphincter
obtain an xray
ATIM: Enteral Feeding A nurse is inserting a small-bore feeding tube. Before initiating the feeding, the nurse should take which of the following actions to verify placement? -measure pH of gastric aspirate -auscultate the epigastric area while injecting air -obtain an xray -place the open end of the tube in a cup of water
persistent coughing
ATIM: Enteral Feeding A nurse is providing teaching about risk for aspiration with a client who is receiving intermittent bolus nasogastric feedings. Which of the following findings should the nurse instruct the client to report? -a feeling of fullness -persistent coughing -discomfort in the naris -postfeeding belching
xiphoid process plus 20-30 cm more
ATIM: Enteral Feeding To determine the length of a nasointestinal tube to insert, a nurse should measure the distance from the tip of the client's nose to the earlobe and from the earlobe to the -umbilicus -xiphoid process -manubrium plus 10-20 cm more -xiphoid process plus 20-30 cm more
limit the time the formula hangs to 8 hr
ATIM: Enteral Feeding A nurse is preparing to administer a continuous enteral tube feeding to a client. The nurse should take which of the following actions to prevent a complication of the tube feeding? -limit the time the formula hangs to 8 hr -flush the tube every 8 hr -deliver the formula at a brisk rate -allow the feeding bag to empty before refilling it
increased abdominal distension
ATIM: Nasogastric Tube A nurse is caring for a client has a nasogastric tube connected to suction. Which of the following findings indicates that the tube has become occluded? -active bowel sounds -passing flatus -increase in gastric secretions -increased abdominal distensions
obtain an xray
ATIM: Nasogastric Tube A nurse is caring for a client who has a newly inserted nasogastric tube. Which of the following actions should the nurse use to verify the initial placement of the tube? -obtain an xray -auscultate injected air -take a pH measurement of gastric aspirate -identify the color of gastric contents
provide frequent mouth care
ATIM: Nasogastric Tube A nurse is caring for a client who is recovering from gastric surgery, is NPO, and has a nasogastric tube connected to suction. Which of the following actions should the nurse take to prevent dry mucous membranes? -allow the client to suck on ice chips -provide frequent mouth care -apply petroleum jelly to the client's naris -offer throat lozenges for the client to use
aspirate stomach contents and check the pH
ATIM: Nasogastric Tube A nurse is checking the client's nasogastric tube for placement. Which of the following procedures should the nurse implement? -instill 20 mL of air into the tube and listen for a whooshing sound -aspirate stomach contents and check the pH -aspirate stomach contents and check their color -auscultate lung sounds
Salem sump tube
ATIM: Nasogastric Tube A nurse is informed during shift report that a client has a nasogastric tube connected to continuous suction. The nurse should identify that this client must have which of the following types of tubes? -Dobhoff tube -Sengstaken-Blakemore tube -Salem sump tube -Ewald tube
inspect the oropharynx with a penlight and a tongue blade
ATIM: Nasogastric Tube A nurse is performing a nasogastric intubation on a client and has reached the tube's predetermined length. Which of the following actions should the nurse take first? -inspect the oropharynx with a penlight and a tongue blade -obtain an xray examination of the chest and abdomen -tape the tube securely in place with a tube holder device -aspirate gastric contents
A 40-year old client who has a postoperative bowel obstruction
ATIM: Nasogastric Tube A nurse is teaching a group of unit nurses about clients who have a need for gastric decompression. The nurse should identify that which of the following clients need nasogastric tube intubation for gastric decompression? -A 6-year old child who ingested a toxic substance -A 60-year old client who has a gastrointestinal hemorrhage -A 40-year old client who has a postoperative bowel obstruction -A 20-year old client who has malabsorption syndrome
the client should be weighed on the same scale at the same time each day
ATIM: Nutrition A charge nurse is reviewing anthropometric values with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? -isolated measurements of height and weight are of greater significance than changes over time -a weight increase of 4lbs in a client who has renal failure indicates a retention of 1000mL of fluid -the client should be weighed on the same scale at the same time each day -the ratio of height to wrist circumference is the most accurate way to identify obesity
elevate the head of the bed 45-90 degrees
ATIM: Nutrition A nurse is caring for a client who has impaired swallowing due to a cerebrovascular accident. Which of the following interventions should the nurse use to assist the client with feeding? -provide the client with a straw -offer the client thin fluids -elevate the head of the bed 45-90 degrees -place food in the weaker side of the mouth
swallowing examination
ATIM: Nutrition A nurse is caring for a client who has sustained a head injury and whose level of consciousness fluctuates. The provider prescribes a full liquid diet progressing to a pureed diet as tolerated. Before initiating feedings, it is essential that this client undergo which of the following? -chest xray -swallowing examination -nasogastric tube insertion -olfactory nerve evlauation
albumin level is a poor short term indicator of protein status
ATIM: Nutrition A nurse is reviewing a client's laboratory values. Which of the following information is correct regarding albumin levels and nutritional status? -albumin level is a poor short term indicator of protein status -hydration status does not affect a client's albumin level -an albumin level of 3.2 g/dL is within the expected reference range -albumin level is calculated by keeping a 24hour record of protein intake
do not offer the child raw vegetables
ATIM: Nutrition When teaching the guardian of a toddler about feeding and eating, the nurse should include which of the following safety measures? -do not give the child peanut butter -have the child drink 28-32 oz of milk daily -give the child 8-12 oz fruit juice daily -do not offer the child raw vegetables
auscultate the client's lungs
ATIM: Nutrition Which of the following actions should a nurse take to assess a client who had a stroke for complications secondary to inadequate swallowing? -auscultate the client's lungs -place the tip of a tongue depressor on the client's posterior tongue -inspect the client's uvula and soft palate with a penlight -place fingers on the client's throat at the level of the larynx and ask the client to swallow
drink water before and after sports activities
ATIM: Nutrition Which of the following dietary modifications should the adolescent who participates in sports implement? -increase fats to 30-40% of daily kilocalories -drink water before and after sports activities -keep protein intake at the same level -decrease carbohydrates to 30-40% of daily kilocalories
plain yogurt, custard, ice cream, gelatin
ATIM: Nutrition Which of the following food choices are appropriate for a client who is prescribed a full liquid diet? (select all that apply) -plain yogurt -custard -ice cream -mashed potatoes -pureed meat -gelatin
consume foods that are low in fiber content
ATIM: Ostomy Care A nurse is obtaining health history from a client who has a colostomy. The client reports frequent episodes of loose stools over the last month but has no signs of infection or bowel obstruction. The client tells the nurse that they have avoided participation in social activities because they are concerned about leakage. Which of the following should the nurse recommend? -consume foods that are low in fiber content -take an ounce of mineral oil twice a day -add buttermilk and cranberry juice to the diet -increase water intake to 3-3.5 L/day
empty the pouch when it is less than half full
ATIM: Ostomy Care A nurse is teaching a client who has a new ileostomy about preventing the excoriation and breakdown of the peristomal skin after they have returned home. Which of the following instructions should the nurse include? -apply hydrocortisone cream to the skin when changing the appliance -empty the pouch when it is less than half full -wash the peristomal skin frequently with deodorizing soap and water -choose a time shortly after a meal for replacing the pouch
Kock's pouch
ATIM: Ostomy Care A nurse is teaching a client who has bladder cancer about urinary diversion options. The nurse should inform the client that which of the following options will allow them to have some control over urinary elimination? -Kock's pouch -ileal conduit -cutaneous ureterostomy -nephrostomy
