Question

ati fundamental test 2024 (nursing process)
60.a nurse is caring for a client who receives intermittent enteral feedings through an ng tube. before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?
a. to confirm the placement of the ng tube
b. to remove gastric acid that might cause dyspepsia
c. to determine the clients electrolyte balance
d. to identify delayed gastric emptying
61.a client receives the wrong medication in error. the nurse who made the medication error should do which of the following first?
a. call the clients provider.
b. observe the client.
c. notify the nurse manager.
d. complete an incident report.
62.a nurse is caring for a client who is postoperative. the nurse should recognize that which of the following methods is the most reliable source when determining the intensity of the clients pain?
a. vital sign measurement
b. clients self - report of pain
c. visual observation for nonverbal signs of pain
d. nature of invasiveness of the surgical procedure
63.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 take prior to administering the tube feeding?
a. warm the feeding solution to body temperature.
b. assist the client to low fowlers position.
c. discard any residual gastric contents.
d. test the ph of gastric aspirate.

Explanation:

• Question 60: Measuring gastric residual helps identify if the stomach is emptying properly (delayed gastric emptying). Confirming NG tube placement is done via pH testing or X - ray (not residual measurement). Removing gastric acid is not the purpose of measuring residual. Electrolyte balance is not determined by gastric residual measurement.
• Question 61: The first action when a medication error occurs is to observe the client for any adverse effects. Calling the provider, notifying the nurse manager, and completing an incident report are important but secondary to client safety (observation).
• Question 62: The client's self - report of pain is the most reliable source as pain is a subjective experience. Vital sign measurement can be affected by many factors other than pain. Visual observation for non - verbal signs is not as reliable as self - report. The nature of the surgical procedure does not directly measure the intensity of the client's pain.
• Question 63: Testing the pH of gastric aspirate is done to confirm NG tube placement in the stomach (a key step before tube feeding). Feeding solutions do not need to be warmed to body temperature. The client should be in at least semi - Fowler's (not low Fowler's) to prevent aspiration. Gastric residuals are usually measured and may be reinstilled (not discarded in most cases).

Answer:

1. D. To identify delayed gastric emptying
2. B. Observe the client
3. B. Client's self - report of pain
4. D. Test the pH of gastric aspirate