Ati mental health proctored exam docx 1f

ATI MENTAL HEALTH
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PROCTORED EXAMu

, ATI MENTAL HEALTH PROCTORED EXAM
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28. The nurse is concerned about pulmonary aspiration when providing thep
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atient with an intermittent tube feeding. Which action is the priority?
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a. Observe the color of gastric contents. u u u u u




b. Verify tube placement before feeding. u u u u


c. Add blue food coloring to the enteral formula.
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d. Run the formula over 12 hours to decrease overload.
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ANS: B u


A major cause of pulmonary aspiration is regurgitation of formula. The nurse needs t
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o verify tube placement and elevate the head of the bed 30 to 45 degrees during feedi
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ngs and for 2 hours afterward. While observing the color of gastric contents is a com
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ponent, it is not the priority component; pH is the primary component. The addition
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of blue food coloring to enteral formula to assist with detection of aspirate is no long
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er used. Do not hang formula longer than 4 to 8 hours. Formula becomes a medium f
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or bacterial growth after that length of time.
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29. The patient is to receive multiple medications via the nasogastric tube. The
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nurse is concerned that the tube may become clogged. Which action is best for thenur
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se to take?
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a. Instill nonliquid medications without diluting. u u u u


b. Irrigate the tube with 60 mL of water aftera u u u u u u u u u


ll medications are given. Mix all medicatio
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ns together to decrease the number of
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c. administrations.
Check with the pharmacy for availability of the liquid forms ofmedicati
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d. ons.
ANS: D u




Use liquid medications when available to prevent tube occlusion. Irrigate with 30 mL
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of water before and after each medication per tube. Completely dissolve crushed me
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dications in liquid if liquid medication is not available. Read pharmacological inform
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ation on compatibility of drugs and formula before mixingmedications.
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30. The patient has just started on enteral feedings, and the patient is reporting
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, abdominal cramping. Which action will the nurse take next?
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a. Slow the rate of tube feeding. u u u u u




b. Instill cold formula to “numb” the stomach.
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c. Change the tube feeding to a high-fat formula.u u u u u u u



d. Consult with the health care provider about prokinetic medication.
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ANS: A u


One possible cause of abdominal cramping is a rapid increase in rate or volume.Low
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ering the rate of delivery may increase tolerance. Another possible cause ofabdomin
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al cramping is the use of cold formula. The nurse should warm the formula to room t
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emperature. High-fat formulas are also a cause of abdominal cramping.
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Consult with the health care provider regarding prokinetic medication forincreasing
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gastric motility for delayed gastric emptying.
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31. The patient has just been started on an enteral feeding and has developed
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diarrhea after being on the feeding for 2 hours. What does the nurse suspect is the
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mostlikely cause of the diarrhea? u u u u


a. Antibiotic therapy u




b. Clostridium difficile u


c. Formula intolerance u



d. Bacterial contamination u




ANS: C u


Hyperosmolar formulas can cause diarrhea or formula intolerance. If that is the cas
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e, the solution is to lower the rate, dilute the formula, or change to an isotonicformu
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la. Antibiotics destroy normal intestinal flora and disturb the internal ecology, allo
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wing for Clostridium difficiletoxin buildup. However, this takes time (more than 2
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hours), and no indication suggests that this patient is on antibiotics. Bacterial conta
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mination of the feeding usually occurs when feedings are left hanging for longer th
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an 8 hours.
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32.A patient develops a foodborne disease from Escherichia coli. When taking a
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health history, which food item will the nurse most likely find the patientingested?
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a. Improperly home-canned food u u




b. Undercooked ground beef u u