24 hours after creation of colostomy nurse violy is correct if she identify that the normal appearance of the stoma is 24 hours after creation of colostomy nurse violy is correct if she identify that the normal appearance of the stoma is
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Nursing Elites

ATI RN

ATI Nutrition Practice Test A 2019

1. 24 hours after the creation of a colostomy, what should Nurse Violy identify as the normal appearance of the stoma?

Correct answer: A

Rationale: Following colostomy surgery, a healthy stoma should appear pink, moist, and slightly protruding from the abdomen, which is why option 'A' is the correct answer. A gray stoma (choice 'B') could indicate poor blood supply or necrosis, which is a serious complication. A dry stoma (choice 'C') is also not normal as it should be moist; a dry stoma may suggest dehydration or other complications. While a stoma can appear red (choice 'D'), this is not typically the normal color; it should usually be pink. Therefore, it's important for healthcare professionals to correctly identify the normal and abnormal appearances of a stoma to ensure proper patient care.

2. A multivitamin supplement containing folic acid is recommended for all young women because of the number of unintentional pregnancies in women 15 to 24 years old.

Correct answer: A

Rationale: Both the statement and the reason are correct and related. A multivitamin with folic acid is recommended for young women due to the high incidence of unplanned pregnancies in this age group.

3. A healthcare professional is performing hearing screenings for children at a community health fair. Which of the following children should the professional refer to a provider for a more extensive hearing evaluation?

Correct answer: D

Rationale: The healthcare professional should refer an infant who is not making babbling sounds by the age of 7 months to a provider for a more extensive evaluation of hearing. Babbling sounds are a developmental milestone that typically occurs by 7 months of age. Delayed or absent babbling can indicate potential hearing issues that warrant further assessment.

4. During a clinical assessment of a 68-year-old client who has suffered a head injury, a neurologist suspects that the client has sustained damage to her vagus nerve (CN X). Which assessment finding is most likely to lead the physician to this conclusion?

Correct answer: B

Rationale: The correct answer is B. Damage to the vagus nerve can result in the loss of the gag reflex, which is a key indicator for the neurologist. Difficulty swallowing (Choice A) is more associated with issues related to the glossopharyngeal nerve (CN IX) and hypoglossal nerve (CN XII). An inability to smell (Choice C) is related to the olfactory nerve (CN I), and impaired eye movement (Choice D) is typically associated with damage to the oculomotor nerve (CN III), trochlear nerve (CN IV), or abducens nerve (CN VI), not the vagus nerve.

5. A client was rushed in the E.R showing a whitish, leathery and painless burned area on his skin. The nurse is correct in classifying this burn as:

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

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