ATI MENTAL HEALTH
g g g
PROCTORED EXAMg
, ATI MENTAL HEALTH PROCTORED EXAM
g g g g
28. The nurse is concerned about pulmonary aspiration when providing thep
g g g g g g g g g g
atient with an intermittent tube feeding. Which action is the priority?
g g g g g g g g g g
a. Observe the color of gastric contents. g g g g g
b. Verify tube placement before feeding. g g g g
c. Add blue food coloring to the enteral formula.
g g g g g g g
d. Run the formula over 12 hours to decrease overload.
g g g g g g g g
ANS: B g
A major cause of pulmonary aspiration is regurgitation of formula. The nurse needs t
g g g g g g g g g g g g g
o verify tube placement and elevate the head of the bed 30 to 45 degrees during feedi
g g g g g g g g g g g g g g g g
ngs and for 2 hours afterward. While observing the color of gastric contents is a com
g g g g g g g g g g g g g g g
ponent, it is not the priority component; pH is the primary component. The addition
g g g g g g g g g g g g g g
of blue food coloring to enteral formula to assist with detection of aspirate is no long
g g g g g g g g g g g g g g g
er used. Do not hang formula longer than 4 to 8 hours. Formula becomes a medium f
g g g g g g g g g g g g g g g g
or bacterial growth after that length of time.
g g g g g g g
29. The patient is to receive multiple medications via the nasogastric tube. The
g g g g g g g g g g g
nurse is concerned that the tube may become clogged. Which action is best for thenur
g g g g g g g g g g g g g g g
se to take?
g g
a. Instill nonliquid medications without diluting. g g g g
b. Irrigate the tube with 60 mL of water aftera g g g g g g g g g
ll medications are given. Mix all medicatio
g g g g g g
ns together to decrease the number of
g g g g g g
c. administrations.
Check with the pharmacy for availability of the liquid forms ofmedicati
g g g g g g g g g g g
d. ons.
ANS: D g
Use liquid medications when available to prevent tube occlusion. Irrigate with 30 mL
g g g g g g g g g g g g
of water before and after each medication per tube. Completely dissolve crushed me
g g g g g g g g g g g g g
dications in liquid if liquid medication is not available. Read pharmacological inform
g g g g g g g g g g g
ation on compatibility of drugs and formula before mixingmedications.
g g g g g g g g g
30. The patient has just started on enteral feedings, and the patient is reporting
g g g g g g g g g g g g
, abdominal cramping. Which action will the nurse take next?
g g g g g g g g
a. Slow the rate of tube feeding. g g g g g
b. Instill cold formula to “numb” the stomach.
g g g g g g
c. Change the tube feeding to a high-fat formula.g g g g g g g
d. Consult with the health care provider about prokinetic medication.
g g g g g g g g
ANS: A g
One possible cause of abdominal cramping is a rapid increase in rate or volume.Low
g g g g g g g g g g g g g g
ering the rate of delivery may increase tolerance. Another possible cause ofabdomin
g g g g g g g g g g g g
al cramping is the use of cold formula. The nurse should warm the formula to room t
g g g g g g g g g g g g g g g g
emperature. High-fat formulas are also a cause of abdominal cramping.
g g g g g g g g g
Consult with the health care provider regarding prokinetic medication forincreasing
g g g g g g g g g g
gastric motility for delayed gastric emptying.
g g g g g g
31. The patient has just been started on an enteral feeding and has developed
g g g g g g g g g g g g
diarrhea after being on the feeding for 2 hours. What does the nurse suspect is the
g g g g g g g g g g g g g g g
mostlikely cause of the diarrhea? g g g g
a. Antibiotic therapy g
b. Clostridium difficile g
c. Formula intolerance g
d. Bacterial contamination g
ANS: C g
Hyperosmolar formulas can cause diarrhea or formula intolerance. If that is the cas
g g g g g g g g g g g g
e, the solution is to lower the rate, dilute the formula, or change to an isotonicformu
g g g g g g g g g g g g g g g g
la. Antibiotics destroy normal intestinal flora and disturb the internal ecology, allo
g g g g g g g g g g g
wing for Clostridium difficiletoxin buildup. However, this takes time (more than 2
g g g g g g g g g g g g
hours), and no indication suggests that this patient is on antibiotics. Bacterial conta
g g g g g g g g g g g g
mination of the feeding usually occurs when feedings are left hanging for longer th
g g g g g g g g g g g g g
an 8 hours.
g g
32.A patient develops a foodborne disease from Escherichia coli. When taking a
g g g g g g g g g g
health history, which food item will the nurse most likely find the patientingested?
g g g g g g g g g g g g g
a. Improperly home-canned food g g
b. Undercooked ground beef g g
g g g
PROCTORED EXAMg
, ATI MENTAL HEALTH PROCTORED EXAM
g g g g
28. The nurse is concerned about pulmonary aspiration when providing thep
g g g g g g g g g g
atient with an intermittent tube feeding. Which action is the priority?
g g g g g g g g g g
a. Observe the color of gastric contents. g g g g g
b. Verify tube placement before feeding. g g g g
c. Add blue food coloring to the enteral formula.
g g g g g g g
d. Run the formula over 12 hours to decrease overload.
g g g g g g g g
ANS: B g
A major cause of pulmonary aspiration is regurgitation of formula. The nurse needs t
g g g g g g g g g g g g g
o verify tube placement and elevate the head of the bed 30 to 45 degrees during feedi
g g g g g g g g g g g g g g g g
ngs and for 2 hours afterward. While observing the color of gastric contents is a com
g g g g g g g g g g g g g g g
ponent, it is not the priority component; pH is the primary component. The addition
g g g g g g g g g g g g g g
of blue food coloring to enteral formula to assist with detection of aspirate is no long
g g g g g g g g g g g g g g g
er used. Do not hang formula longer than 4 to 8 hours. Formula becomes a medium f
g g g g g g g g g g g g g g g g
or bacterial growth after that length of time.
g g g g g g g
29. The patient is to receive multiple medications via the nasogastric tube. The
g g g g g g g g g g g
nurse is concerned that the tube may become clogged. Which action is best for thenur
g g g g g g g g g g g g g g g
se to take?
g g
a. Instill nonliquid medications without diluting. g g g g
b. Irrigate the tube with 60 mL of water aftera g g g g g g g g g
ll medications are given. Mix all medicatio
g g g g g g
ns together to decrease the number of
g g g g g g
c. administrations.
Check with the pharmacy for availability of the liquid forms ofmedicati
g g g g g g g g g g g
d. ons.
ANS: D g
Use liquid medications when available to prevent tube occlusion. Irrigate with 30 mL
g g g g g g g g g g g g
of water before and after each medication per tube. Completely dissolve crushed me
g g g g g g g g g g g g g
dications in liquid if liquid medication is not available. Read pharmacological inform
g g g g g g g g g g g
ation on compatibility of drugs and formula before mixingmedications.
g g g g g g g g g
30. The patient has just started on enteral feedings, and the patient is reporting
g g g g g g g g g g g g
, abdominal cramping. Which action will the nurse take next?
g g g g g g g g
a. Slow the rate of tube feeding. g g g g g
b. Instill cold formula to “numb” the stomach.
g g g g g g
c. Change the tube feeding to a high-fat formula.g g g g g g g
d. Consult with the health care provider about prokinetic medication.
g g g g g g g g
ANS: A g
One possible cause of abdominal cramping is a rapid increase in rate or volume.Low
g g g g g g g g g g g g g g
ering the rate of delivery may increase tolerance. Another possible cause ofabdomin
g g g g g g g g g g g g
al cramping is the use of cold formula. The nurse should warm the formula to room t
g g g g g g g g g g g g g g g g
emperature. High-fat formulas are also a cause of abdominal cramping.
g g g g g g g g g
Consult with the health care provider regarding prokinetic medication forincreasing
g g g g g g g g g g
gastric motility for delayed gastric emptying.
g g g g g g
31. The patient has just been started on an enteral feeding and has developed
g g g g g g g g g g g g
diarrhea after being on the feeding for 2 hours. What does the nurse suspect is the
g g g g g g g g g g g g g g g
mostlikely cause of the diarrhea? g g g g
a. Antibiotic therapy g
b. Clostridium difficile g
c. Formula intolerance g
d. Bacterial contamination g
ANS: C g
Hyperosmolar formulas can cause diarrhea or formula intolerance. If that is the cas
g g g g g g g g g g g g
e, the solution is to lower the rate, dilute the formula, or change to an isotonicformu
g g g g g g g g g g g g g g g g
la. Antibiotics destroy normal intestinal flora and disturb the internal ecology, allo
g g g g g g g g g g g
wing for Clostridium difficiletoxin buildup. However, this takes time (more than 2
g g g g g g g g g g g g
hours), and no indication suggests that this patient is on antibiotics. Bacterial conta
g g g g g g g g g g g g
mination of the feeding usually occurs when feedings are left hanging for longer th
g g g g g g g g g g g g g
an 8 hours.
g g
32.A patient develops a foodborne disease from Escherichia coli. When taking a
g g g g g g g g g g
health history, which food item will the nurse most likely find the patientingested?
g g g g g g g g g g g g g
a. Improperly home-canned food g g
b. Undercooked ground beef g g
