what sensation is used as a gauge so that patients with ileostomy can determine how often their pouch should be drained
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Nursing Elites

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Nutrition ATI Test

1. What sensation is used as a gauge so that patients with ileostomy can determine how often their pouch should be drained?

Correct answer: B

Rationale: The correct answer is B: Sensation of pressure. Patients with ileostomy can determine how often their pouch should be drained by feeling the sensation of pressure. This is important as it helps prevent leakage or overflow of the pouch. The sensation of taste (choice A) and smell (choice C) are not typically used as gauges for draining the pouch in ileostomy patients. The urge to defecate (choice D) is not relevant in this context as patients with ileostomy do not pass stool through the rectum.

2. Angie is a disoriented client who frequently falls from the bed. As her nurse, which of the following is the best nursing intervention to prevent future falls?

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

3. Mang Carlos has been terminally ill for 5 years. He asked his wife to decide for him when he is no longer capable to do so. As a Nurse, You know that this is called:

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

4. Each statement is true of vitamin K, except one. Which is the exception?

Correct answer: D

Rationale: The correct answer is D. Vitamin K absorption decreases with high levels of vitamin E supplementation because in larger amounts, vitamin E acts as an anticoagulant. Vitamin K is not produced in the gut but can be obtained from food sources or supplements. Vitamin K is essential for the synthesis of blood-clotting factors and is crucial in maintaining prothrombin levels, which is vital for proper blood clotting. The incorrect choice, D, is misleading as high levels of vitamin E supplementation hinder vitamin K absorption due to its anticoagulant properties. Dental hygienists should be aware of the importance of vitamin K in blood clotting, especially when treating patients who are on anticoagulant medications for conditions like stroke prevention.

5. In some hip surgeries, an epidural catheter for Fentanyl epidural analgesia is given. What is your nursing priority care in such a case?

Correct answer: D

Rationale: The nursing priority care in a case where an epidural catheter for Fentanyl epidural analgesia is given during hip surgeries is to assess the respiratory rate carefully. Respiratory depression is a potential side effect of Fentanyl, especially when administered epidurally. Monitoring the respiratory rate is crucial to detect any signs of respiratory distress promptly. Instructing the client to observe strict bed rest (Choice A) may be necessary but is not the priority over ensuring respiratory function. Checking for epidural catheter drainage (Choice B) and administering analgesia through the epidural catheter as prescribed (Choice C) are important aspects of care, but ensuring adequate ventilation takes precedence to prevent complications.

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