what is the most important nursing intervention for a patient with diarrhea

ATI RN

ATI Capstone Comprehensive Assessment B

1. What is the most important nursing intervention for a patient with diarrhea?

A. Encourage the patient to increase fluid intake.
B. Monitor the patient's skin integrity.
C. Check the patient's electrolyte levels.
D. Educate the patient about infection control measures.

Correct answer: B

Rationale: The correct answer is to monitor the patient's skin integrity. This is crucial because diarrhea can lead to skin breakdown due to frequent bowel movements and increased moisture in the perineal area. By monitoring skin integrity, nurses can prevent skin breakdown, infection, and other associated issues. Encouraging fluid intake (Choice A) is important but not the most critical intervention. Checking electrolyte levels (Choice C) is essential but may not be the top priority at the onset. Educating the patient about infection control (Choice D) is important but secondary to preventing skin breakdown in a patient with diarrhea.

2. What are the nursing interventions for a patient with pneumonia?

A. Providing fluids and rest
B. Monitoring lung sounds and respiratory rate
C. Encouraging coughing and deep breathing exercises
D. Administering antibiotics and providing oxygen therapy

Correct answer: B

Rationale: The correct nursing interventions for a patient with pneumonia include monitoring lung sounds and respiratory rate to assess the effectiveness of treatment and the patient's respiratory status. Providing fluids and rest (Choice A) can be supportive measures but are not specific nursing interventions for pneumonia. Encouraging coughing and deep breathing exercises (Choice C) can be helpful for airway clearance but may not be appropriate for all patients with pneumonia. Administering antibiotics and providing oxygen therapy (Choice D) are medical interventions rather than nursing interventions.

3. A nurse is teaching a patient with hypertension about the DASH diet. What is the most important instruction to include?

A. Increase the patient's intake of fruits and vegetables.
B. Limit the patient's intake of saturated fats.
C. Encourage the patient to reduce sodium intake.
D. Recommend the patient avoid caffeine.

Correct answer: C

Rationale: The correct answer is to encourage the patient to reduce sodium intake. The Dietary Approaches to Stop Hypertension (DASH) diet emphasizes reducing sodium intake to help manage hypertension. While increasing fruits and vegetables (Choice A) is important in the DASH diet, reducing sodium intake is considered more crucial. Limiting saturated fats (Choice B) is beneficial but not as critical as reducing sodium. Avoiding caffeine (Choice D) is not a specific recommendation of the DASH diet for managing hypertension.

4. A hospice nurse is providing teaching to a client who has a new diagnosis of a terminal illness and her family. Which of the following statements should the nurse include in the teaching?

A. Hospice care focuses on providing comfort and symptom management.
B. The provider will coordinate your health care needs while in hospice.
C. You do not need to choose a family caregiver before being admitted into a hospice facility.
D. Hospice care continues to help families with grief after a death occurs.

Correct answer: D

Rationale: The correct answer is D because hospice care provides ongoing support to families with grief even after a patient's death. Choice A is incorrect because hospice care focuses on providing comfort and symptom management rather than disease treatment and rehabilitation. Choice B is incorrect as the statement does not accurately reflect the role of a hospice provider. Choice C is incorrect; a family caregiver is not a prerequisite for admission into a hospice facility.

5. The client has a do-not-resuscitate (DNR) order. The family asks the nurse to ignore the DNR if the client codes. What is the nurse's responsibility?

A. Follow the family's wishes
B. Explain that the DNR must be honored
C. Ignore the DNR and proceed with CPR
D. Perform CPR if the client codes

Correct answer: B

Rationale: The correct answer is B: 'Explain that the DNR must be honored.' The nurse's responsibility is to follow the DNR order, as it is a legal and ethical obligation. Choice A is incorrect because following the family's wishes would go against the established DNR order. Choice C is incorrect as ignoring the DNR order is not appropriate. Choice D is also incorrect as performing CPR would be contrary to the client's expressed wishes in the DNR order.