a nurse is giving discharge instructions to a client who has a new ileostomy the nurse should recognize that the teaching has been effective when the
Logo

Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment A

1. A nurse is giving discharge instructions to a client who has a new ileostomy. The nurse should recognize that the teaching has been effective when the client states:

Correct answer: B

Rationale: The correct answer is B. When a client with an ileostomy states that their stoma will drain liquid continuously, it indicates an understanding of the expected outcome. In an ileostomy, the stoma continuously drains liquid stool as it bypasses the large intestine where water is absorbed. Choices A, C, and D are incorrect because ensuring medications are enteric-coated, changing the pouch system every two weeks, and expecting the stoma size to remain the same after healing are not accurate statements related to an ileostomy.

2. A nurse is providing education on the use of aspirin. Which of the following should be included?

Correct answer: A

Rationale: The correct answer is A: 'It can increase the risk of bleeding.' Aspirin is known to have antiplatelet effects and can increase the risk of bleeding, especially if taken in high doses or for prolonged periods. Choice B is incorrect because aspirin is not safe for children due to the risk of Reye's syndrome. Choice C is incorrect because aspirin should be taken with food to minimize gastrointestinal side effects. Choice D is incorrect because aspirin, like any medication, can have side effects, such as gastrointestinal bleeding, ulcers, or allergic reactions.

3. A client with a history of seizures is being cared for by a nurse. Which of the following interventions should the nurse prioritize?

Correct answer: A

Rationale: The nurse should prioritize ensuring the environment is safe for a client with a history of seizures. This intervention is crucial to prevent injury during a seizure. Administering medications as prescribed is important but ensuring a safe environment takes precedence to prevent harm. Monitoring for signs of infection and educating the client about triggers are also essential aspects of care but are not the priority when considering the immediate safety of the client during a seizure.

4. A nurse has been caring for a female client who has bruises on her arms that she explains are a result of physical abuse by her husband. The client states, “I don’t know how much longer I can take this, but I’m afraid he’ll really hurt me if I leave.” Which of the following is an appropriate nursing intervention?

Correct answer: D

Rationale: Assisting the client in reporting the abuse is a critical step in ensuring her safety and initiating legal action to protect her from further harm. Option A is inappropriate as it may escalate the situation and put the client at further risk. Option B focuses on the client recognizing signs of abuse, which is not as urgent as reporting it to authorities. Option C places the responsibility on the client for triggering the abuse, which is victim-blaming and not helpful in this context.

5. A nurse is caring for a client who has congestive heart failure and is taking digoxin. The client reports nausea and refuses to eat breakfast. Which of the following actions should the nurse take first?

Correct answer: D

Rationale: The correct answer is to check the client's apical pulse first. Nausea can be a sign of digoxin toxicity, and assessing the client's heart rate is crucial in this situation. Administering an antiemetic or encouraging the client to eat should come after ensuring the client's safety. While informing the provider is important, the immediate concern is to assess for potential digoxin toxicity by checking the client's apical pulse.

Similar Questions

A nurse is reviewing the medication metformin with a client who has diabetes. Which of the following side effects should the nurse discuss?
A nurse is teaching a client who is taking prednisone about the adverse effects of this medication. Which of the following should the nurse emphasize?
A client with Ménière’s disease is experiencing episodes of vertigo. Which of the following interventions should the nurse include in the plan?
A nurse reviewing a patient’s care plan notes a goal of 'Patient will ambulate 50 feet three times in the hallway today.' Which domain of Bloom’s taxonomy is this goal in?
A healthcare professional is reviewing the health history of an older adult who has a hip fracture. What is a risk factor for developing pressure injuries?

Access More Features

ATI LPN Basic
$69.99/ 30 days

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

ATI LPN Premium
$149.99/ 90 days

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

Other Courses