ATI FUNDAMENTALS HESI EXIT RN EXAM TESTBANK 402QUESTIONS AND ANSWERS WITH RATIONALES Latest Update 2023/2024 GRADED A+ SCORES

ATI FUNDAMENTALS HESI EXIT RN EXAM TESTBANK 402QUESTIONS AND ANSWERS WITH RATIONALES Latest Update 2023/2024 GRADED A+ SCORES 100.A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the client’s insomnia? A.The client watches television in her bed during the day. -To promote sleep, the client should avoid watching television in bed. She should use the bed only for sleep or sexual activities. B.The client drinks warm milk before bedtime. -incorrect: Warm milk provides L-tryptophan, an amino acid that promotes sleep. C.The client goes to bed at 2200 every night. -incorrect: General sleep strategies include establishing a regular sleep schedule. A nightly bedtime of 2200 could be part of a bedtime routine to promote sleep. D.The client gets up to use the bathroom once during the night. -incorrect: Although this can cause nighttime disruptions, waking once or twice to use the bathroom at night is common. Adults who do not have insomnia issues fall back to sleep readily. 101.A nurse is preparing to administer a feeding via gastrostomy tube to a client who had a stroke. Which of the following actions should the nurse take prior to initiating the feeding? A.Warm the feeding in a microwave oven -incorrect: Although cold enteral formula could cause cramping, it is not necessary to warm the feeding prior to administration. The formula should be at room temperature to improve the client’s tolerance of gastrostomy feedings. Also, warming the formula in a microwave oven can cause uneven heat distribution and excessive heat; therefore, it’s not a safe way to warm enteral feedings. B.Elevate the head of the client’s bed -Clients who have a brain injury are typically unable to swallow effectively and thus cannot protect their airway from aspiration. Even though this route bypasses the nasopharynx, it is still possible for the client to cough or vomit enteral formula into the oral cavity. Consequently, the nurse should strive to prevent aspiration by elevating the head of the bed prior to initiating the feeding. C.Flush the tube with 0.9% sodium chloride for irrigation -incorrect: The nurse should flush the tube with water prior to initiating the feeding to ensure the patency of the tube. D.Verify that the client’s gastric pH is above 4 -incorrect: Due to the acidity of gastric secretions, the pH of gastric contents should be below 4 to indicate proper placement of the gastrostomy tube. A pH above 4 suggests that the end of the tube is not in the stomach. 102.A nurse is assessing a client’s nutritional status. The nurse determines the client is consuming 500 calories more per day than his energy level requires. If his dietary habits do not change, how long will it take the client to gain 4.5 kg (10lb)? A.10 months B.5 months -incorrect: At the rate of 1 lb per week, the client would gain 20-25 lb in 5 months.