NUR 3480- MED SURGE EXAM 4-ATI QUESTIONS AND CORRECT ANSWERS LATEST 2025
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) A feeling if fullness
B) Persistent Coughing
C) Discomfort in the naris
D) Post-feeding belching - Answers B) Persistent coughing
Rationale: A persistent cough can indicate that the distal end of the nasogastric tube has moved
into the respiratory tract. The client should report this finding to the nurse immediately because
this is a risk for aspiration
A client who lives in a long-term care facility is receiving intermittent enteral feedings and is
experiencing social isolation. Which of the following interventions should the nurse recommend?
A) Encourage the client to go to the dining room at meal times to talk with other clients
B) suggest that the client watch television while feedings are being administered
C) Remind the client that they have visitors after feeding administration times
C) Ask the facility chaplain to speak with the client - Answers A) Encourage the client to go to
the dining room at meal times to talk with other clients
Rationale: By Encouraging the resident to maintain a normal schedule and social interactions,
the nurse is helping to promote socialization and reverse patterns of isolation
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?
,A) Limit the time the formula hangs to 8 hr
B) Flush the tube every 8 hr.
C) Deliver the formula at a brisk rate
D) Allow the feeding bag to empty before refilling it - Answers A) Limit the time the formula
hangs to 8 hr
Rationale: Formula that hangs longer than 12 hr for an open system and 48 hr. for a closed
system is at risk for spoilage of the formula or bacterial contamination, typically manifested as
diarrhea
To determine the length of a nasointestinal tube to insert, a nurse should measure the distance
form the tip of the client's nose to the earlobe and from the earlobe to the
A) umbilicus
B) xiphoid process
C) manubrium plus 10 to 20 cm more
D) xiphoid process plus 20 to 30 cm more. - Answers D) xiphoid process plus 20 to 30 cm more
Rationale: Measuring form the tip of the nose to the earlobe to the xiphoid process
approximates the distance from the nose to the stomach form 98% of clients. For duodenal or
jejunal placement, an additional 20 to 30 cm is required.
A nurse is caring for a client who has a significant risk of aspiration and requires nutritional
support for about 2 weeks because they are unable to consume adequate nutrients orally.
Which of the following types of feeding tubes should the nurse anticipate the provider to
prescribe?
A) Nasogastric tube
B) Nasointestinal tube
C) Percutaneous endoscopic gastrostomy tube
, D) Percutaneous endoscopic jejunotomy tube - Answers B) Nasointestinal Tube
Rationale: A nasointestinal tube is recommended for clients at a high risk of aspiration who
require short-term feedings of less than 4 weeks
A nurse is caring for a client who has a dysfunctional gastrointestinal tract and requires enteral
feeding. Which of the following formulas should the nurse administer to the client?
A) Modular
B) Elemental
C) Polymeric
D) Specialty - Answers B) Elemental
Rationale: Elemental formulas contain predigested nutrients that are easy for a partially
functional gastrointestinal tract to absorb
A nurse is administering an enteral tube feeding to a client. Which of the following actions
should the nurse take to prevent aspiration?
A) Flush the feeding tube with 30 mL of water
B) Add blue food coloring to the enteral formula
C) Ensure the formula is at room temperature
D) Place the client in Fowler's position - Answers D) Place the client in Fowler's position
Rationale:Positioning a client in Fowler's position during a tube feeding can reduce the risk of
regurgitation, which can lead to aspiration. If Fowler's is uncomfortable or contraindicated for
the client, elevate the head of the client's bed to at least 30 degrees
A nurse is inserting a nasogastric tube for a client and asks the client to flex their head toward
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) A feeling if fullness
B) Persistent Coughing
C) Discomfort in the naris
D) Post-feeding belching - Answers B) Persistent coughing
Rationale: A persistent cough can indicate that the distal end of the nasogastric tube has moved
into the respiratory tract. The client should report this finding to the nurse immediately because
this is a risk for aspiration
A client who lives in a long-term care facility is receiving intermittent enteral feedings and is
experiencing social isolation. Which of the following interventions should the nurse recommend?
A) Encourage the client to go to the dining room at meal times to talk with other clients
B) suggest that the client watch television while feedings are being administered
C) Remind the client that they have visitors after feeding administration times
C) Ask the facility chaplain to speak with the client - Answers A) Encourage the client to go to
the dining room at meal times to talk with other clients
Rationale: By Encouraging the resident to maintain a normal schedule and social interactions,
the nurse is helping to promote socialization and reverse patterns of isolation
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?
,A) Limit the time the formula hangs to 8 hr
B) Flush the tube every 8 hr.
C) Deliver the formula at a brisk rate
D) Allow the feeding bag to empty before refilling it - Answers A) Limit the time the formula
hangs to 8 hr
Rationale: Formula that hangs longer than 12 hr for an open system and 48 hr. for a closed
system is at risk for spoilage of the formula or bacterial contamination, typically manifested as
diarrhea
To determine the length of a nasointestinal tube to insert, a nurse should measure the distance
form the tip of the client's nose to the earlobe and from the earlobe to the
A) umbilicus
B) xiphoid process
C) manubrium plus 10 to 20 cm more
D) xiphoid process plus 20 to 30 cm more. - Answers D) xiphoid process plus 20 to 30 cm more
Rationale: Measuring form the tip of the nose to the earlobe to the xiphoid process
approximates the distance from the nose to the stomach form 98% of clients. For duodenal or
jejunal placement, an additional 20 to 30 cm is required.
A nurse is caring for a client who has a significant risk of aspiration and requires nutritional
support for about 2 weeks because they are unable to consume adequate nutrients orally.
Which of the following types of feeding tubes should the nurse anticipate the provider to
prescribe?
A) Nasogastric tube
B) Nasointestinal tube
C) Percutaneous endoscopic gastrostomy tube
, D) Percutaneous endoscopic jejunotomy tube - Answers B) Nasointestinal Tube
Rationale: A nasointestinal tube is recommended for clients at a high risk of aspiration who
require short-term feedings of less than 4 weeks
A nurse is caring for a client who has a dysfunctional gastrointestinal tract and requires enteral
feeding. Which of the following formulas should the nurse administer to the client?
A) Modular
B) Elemental
C) Polymeric
D) Specialty - Answers B) Elemental
Rationale: Elemental formulas contain predigested nutrients that are easy for a partially
functional gastrointestinal tract to absorb
A nurse is administering an enteral tube feeding to a client. Which of the following actions
should the nurse take to prevent aspiration?
A) Flush the feeding tube with 30 mL of water
B) Add blue food coloring to the enteral formula
C) Ensure the formula is at room temperature
D) Place the client in Fowler's position - Answers D) Place the client in Fowler's position
Rationale:Positioning a client in Fowler's position during a tube feeding can reduce the risk of
regurgitation, which can lead to aspiration. If Fowler's is uncomfortable or contraindicated for
the client, elevate the head of the client's bed to at least 30 degrees
A nurse is inserting a nasogastric tube for a client and asks the client to flex their head toward
