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 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
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Nursing Elites

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?

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 urine test result is considered abnormal?

Correct answer: A

Rationale: A urine pH of 4.0 is abnormally low, indicating possible acidosis or other metabolic conditions. WBC count of 1-2 cells/ml, absence of protein, and a specific gravity of 1.020 are within normal limits.

3. When assessing a child with leukemia, which clinical manifestations should the nurse anticipate?

Correct answer: A

Rationale: The correct answer is A: Petechiae, fever, fatigue. Children with leukemia commonly present with petechiae (due to low platelet count), fever (due to infection), and fatigue (due to anemia), which are classic manifestations of the disease. Option B is incorrect because headache, papilledema, and irritability are more indicative of increased intracranial pressure, not leukemia. Option C is incorrect as muscle wasting and weight loss are not typical initial manifestations of leukemia in children. Option D is incorrect as decreased intracranial pressure, psychosis, and confusion are not commonly associated with leukemia.

4. A client has been prescribed Atorvastatin to lower cholesterol. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct instruction for the nurse to include is to 'Report any muscle pain to your provider immediately.' Muscle pain can be a sign of rhabdomyolysis, a rare but serious side effect of statins like atorvastatin. It is crucial to monitor for potential complications, and reporting muscle pain promptly can lead to timely intervention if needed. Choices A, C, and D are incorrect because they do not address a critical side effect of atorvastatin or provide essential information for the client's safety and well-being.

5. Does alcohol contain energy and is therefore a nutrient?

Correct answer: B

Rationale: Alcohol does contain energy and provides calories, but it is not considered a nutrient. Nutrients are substances that contribute to essential bodily functions. While alcohol may have energy, it does not provide essential vitamins, minerals, or other nutrients necessary for the body's health. Additionally, excessive alcohol consumption can have harmful effects on the body, further supporting why alcohol is not classified as a nutrient.

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