a nurse is caring for a client with a new colostomy what is the nurses responsibility regarding stoma care
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 A with NGN

1. A nurse is caring for a client with a new colostomy. What is the nurse's responsibility regarding stoma care?

Correct answer: B

Rationale: The correct answer is to contact the stoma nurse to assist the client with care. Stoma nurses are specially trained to provide guidance on stoma care, especially for clients with new ostomies. Instructing the client to care for the stoma independently (Choice A) may not be appropriate initially as they may need professional guidance. Delegating the care of the stoma to a nursing assistant (Choice C) is not recommended as specialized care is required. Waiting until the next shift (Choice D) is not ideal as stoma care should not be delayed.

2. A nurse is caring for a client with pneumonia who has a new prescription for antibiotics. Which of the following actions should the nurse take first?

Correct answer: B

Rationale: The correct first action for the nurse to take when caring for a client with pneumonia who has a new prescription for antibiotics is to obtain a sputum culture. This is important to identify the specific bacteria causing the pneumonia before administering antibiotics. Administering the antibiotic immediately (Choice A) may not be appropriate without knowing the specific pathogen. Notifying the provider of the prescription (Choice C) is important but not the first action to be taken. Checking the client's allergy history (Choice D) is relevant but not the priority in this situation.

3. A patient with chronic obstructive pulmonary disease (COPD) is being cared for by a nurse. What is the most appropriate action to improve the patient's oxygenation?

Correct answer: B

Rationale: Administering oxygen via nasal cannula as prescribed is the most appropriate action to improve the patient's oxygenation in COPD. Oxygen therapy helps maintain adequate oxygen levels in the blood, which is crucial for managing COPD. Encouraging the use of incentive spirometry, assisting with coughing and deep breathing exercises, and positioning the patient in high Fowler's position are all beneficial interventions, but administering oxygen is the priority for immediate oxygenation support in COPD.

4. A patient receiving chemotherapy has developed neutropenia. What should be included in the care plan to reduce infection risk?

Correct answer: D

Rationale: When a patient receiving chemotherapy develops neutropenia, the priority is to reduce the risk of infection. Using reverse isolation precautions is crucial in this situation to protect the patient from exposure to pathogens. Monitoring temperature daily (Choice A) is important but is not as effective as isolating the patient. Limiting visitors (Choice B) can help reduce the risk of exposure, but reverse isolation is a more stringent measure. Administering antibiotics prophylactically (Choice C) is not recommended unless there is a specific indication, as it can contribute to antibiotic resistance.

5. The nurse is preparing a care plan for a patient who is immobile. Which psychosocial aspect will the nurse assess for?

Correct answer: C

Rationale: When a patient is immobile, the nurse should assess for psychosocial aspects, including a loss of hope and increased risk of depression. While issues like weight loss (choice A), loss of bone mass (choice B), and loss of strength (choice D) can also occur due to immobility, the primary concern in this scenario is the patient's mental and emotional well-being, making 'Loss of hope' the correct answer.

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