the nurse is caring for the client one 1 day postoperative sigmoid colostomy operation which independent nursing intervention should the nurse impleme
Logo

Nursing Elites

ATI RN

ATI RN Custom Exams Set 3

1. The nurse is caring for the client one (1) day postoperative sigmoid colostomy operation. Which independent nursing intervention should the nurse implement?

Correct answer: D

Rationale: Assisting the client to sit in a chair is a crucial nursing intervention postoperatively. It helps prevent complications such as thrombosis, pneumonia, and pressure ulcers by promoting circulation and aiding in recovery. Changing the infusion rate of the intravenous fluid would require a physician's order and is not within the nurse's independent scope of practice. Encouraging the client to discuss feelings and administering medications for pain management are important interventions but may not be as immediately necessary as assisting the client in mobilizing early postoperatively.

2. Identifying the strengths and weaknesses in the plan of nursing care is part of which of the following steps in determining and fulfilling the nursing care needs of the patient?

Correct answer: A

Rationale: The correct answer is A: Evaluation. Evaluation in nursing care involves assessing the effectiveness of the care plan, identifying strengths, weaknesses, and areas for improvement. This step helps ensure that the patient's needs are being met appropriately. Planning (choice B) involves developing the care plan based on the assessment data. Implementation (choice C) is the step where the care plan is put into action. Assessment (choice D) is the initial step in the nursing process that involves collecting and analyzing data about the patient's health status.

3. What type of diet is recommended for patients with diverticulitis during an acute flare-up?

Correct answer: B

Rationale: During an acute flare-up of diverticulitis, a low-residue diet is recommended. This diet helps reduce bowel movements and minimize irritation to the digestive tract, allowing the inflamed diverticula to heal. High-fiber foods are usually avoided during flare-ups as they can exacerbate symptoms. Low-fat and high-protein diets are not specifically recommended for diverticulitis flare-ups. Therefore, option B is the correct choice.

4. Determining whether the care provided is appropriate and effective in relation to the patient's current physiological and psychological status is a part of which of the following steps for determining and fulfilling the nursing care needs of the patient?

Correct answer: A

Rationale: The correct answer is A: Evaluation. Evaluation involves assessing the appropriateness and effectiveness of care provided to the patient. It helps determine if the care aligns with the patient's current physiological and psychological status. Choice B, Planning, refers to developing a plan of care based on assessment data. Choice C, Implementation, involves carrying out the planned interventions. Choice D, Assessment, is the initial step that involves collecting data about the patient's condition.

5. A patient is prescribed an oral anticoagulant. What should the nurse monitor for?

Correct answer: C

Rationale: Correct! When a patient is prescribed an oral anticoagulant, the nurse should monitor for signs of bleeding. Oral anticoagulants are medications that prevent blood clot formation but can increase the risk of bleeding. Monitoring for signs such as easy bruising, blood in urine or stool, and prolonged bleeding from minor cuts is essential. Choices A, B, and D are incorrect because oral anticoagulants do not typically affect blood glucose levels, blood pressure, or appetite.

Similar Questions

The nurse is caring for a client in a sickle cell crisis. Which is the pain regimen of choice to relieve the pain?
For a patient on lithium therapy, which dietary recommendation is essential?
The client has recently been diagnosed with irritable bowel syndrome (IBS). Which intervention should the nurse teach the client to reduce symptoms?
The nurse is administering a beta blocker to the client diagnosed with essential hypertension. Which data would cause the nurse to question administering the medication?
A nurse administers albuterol to a child with asthma. For what common side effect should the nurse monitor the child?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses