a nurse is caring for a client who is 3 days postoperative following a colostomy which of the following findings should the nurse report to the provid

ATI RN

ATI Exit Exam RN

1. A nurse is caring for a client who is 3 days postoperative following a colostomy. Which of the following findings should the nurse report to the provider?

A. Stoma that is red and moist
B. Purulent drainage from the stoma
C. Stoma that is dry and purple
D. Mild swelling around the stoma

Correct answer: C

Rationale: A dry, purple stoma is abnormal and may indicate compromised blood flow, which should be reported to the provider. A red and moist stoma is a normal finding postoperatively. Purulent drainage from the stoma indicates infection and should also be reported. Mild swelling around the stoma is common in the early postoperative period and does not typically require immediate reporting.

2. What is the priority nursing intervention for a patient with a stage 3 pressure ulcer?

A. Apply hydrocolloid dressing
B. Provide wound debridement
C. Change the dressing daily
D. Elevate the affected area

Correct answer: A

Rationale: The correct answer is to apply a hydrocolloid dressing. Stage 3 pressure ulcers are characterized by full-thickness skin loss involving damage to or necrosis of subcutaneous tissue, which requires a moist environment for healing. Hydrocolloid dressings help maintain a moist wound environment, promote healing, and provide protection. Providing wound debridement may be necessary but is not the priority intervention at this stage. Changing the dressing daily is important for wound care but not the priority over creating an optimal healing environment. Elevating the affected area can help with circulation and reduce swelling, but it is not the priority intervention for a stage 3 pressure ulcer.

3. A nurse is providing teaching to a client who is experiencing preterm contractions and dehydration. Which statement should the nurse make?

A. Dehydration is treated with calcium supplements.
B. Dehydration can increase the risk of preterm labor.
C. Dehydration is caused by decreased hemoglobin and hematocrit.
D. Dehydration causes gastroesophageal reflux.

Correct answer: B

Rationale: The correct statement is B: 'Dehydration can increase the risk of preterm labor.' Dehydration can lead to increased uterine irritability, potentially causing preterm contractions and labor. Choice A is incorrect as dehydration is not treated with calcium supplements but rather with fluids. Choice C is incorrect as dehydration is not caused by decreased hemoglobin and hematocrit levels but rather by a lack of fluids. Choice D is incorrect as dehydration does not directly cause gastroesophageal reflux.

4. How should a healthcare provider care for a patient with a tracheostomy?

A. Clean the tracheostomy site daily
B. Change the tracheostomy ties daily
C. Suction the tracheostomy regularly
D. Provide humidified oxygen

Correct answer: C

Rationale: Suctioning the tracheostomy regularly is crucial in caring for a patient with a tracheostomy as it helps keep the airway clear of secretions, preventing blockages and potential complications. Cleaning the tracheostomy site daily is important for hygiene but not as critical as regular suctioning. Changing the tracheostomy ties daily may not be necessary unless soiled or loose. Providing humidified oxygen may be part of the care plan but is not as directly related to maintaining the tracheostomy patency as suctioning.

5. What is the appropriate diet for a patient with chronic kidney disease?

A. Low protein diet
B. High protein diet
C. Low sodium diet
D. Low potassium diet

Correct answer: A

Rationale: A low protein diet is the appropriate choice for a patient with chronic kidney disease because it helps to reduce the buildup of waste products in the body, which the kidneys may struggle to filter out. High protein diets can put extra strain on the kidneys by increasing the workload to eliminate the byproducts of protein metabolism. While low sodium and low potassium diets can also be important for managing certain aspects of kidney disease, the primary focus should be on controlling protein intake to lessen the burden on the kidneys.