how should a nurse care for a patient with a colostomy

ATI LPN

ATI Comprehensive Predictor PN

1. How should a healthcare professional care for a patient with a colostomy?

A. Empty the colostomy bag regularly
B. Provide a high-fiber diet
C. Monitor for signs of infection
D. Change the colostomy bag every 3 days

Correct answer: A

Rationale: Emptying the colostomy bag regularly is essential to prevent leakage and infection. By regularly emptying the bag, the risk of irritation to the skin surrounding the stoma is reduced. Providing a high-fiber diet is important for overall bowel health but is not directly related to colostomy care. While monitoring for signs of infection is crucial, the primary focus should be on proper bag emptying. Changing the colostomy bag every 3 days may not be necessary for all patients and could vary based on individual needs and the type of colostomy.

2. What are the key factors in assessing a patient's fall risk?

A. Assess the patient's age and mobility
B. Evaluate the patient's medication list for sedatives
C. Assess the patient's vision and hearing
D. Check for recent falls and cognitive impairment

Correct answer: A

Rationale: The correct answer is A. Assessing the patient's age and mobility are key factors in determining fall risk. Age can affect balance and reaction time, while mobility influences the patient's stability. Choices B, C, and D are important considerations in assessing a patient's fall risk as well, but age and mobility play a more direct role in determining the patient's susceptibility to falls.

3. When providing discharge instructions for a client prescribed home oxygen, what is an essential safety measure?

A. Ensure the client has cotton bedding
B. Keep the oxygen equipment away from heat sources
C. Use wool blankets to ensure warmth
D. Allow the client to use electronic devices near the oxygen supply

Correct answer: B

Rationale: The correct answer is B: 'Keep the oxygen equipment away from heat sources.' Placing oxygen equipment near heat sources can lead to fire hazards due to the flammability of oxygen. Cotton bedding or wool blankets are not directly related to oxygen safety measures. Allowing electronic devices near the oxygen supply can increase the risk of fire due to potential sparks or heat generated.

4. What is the priority intervention for sepsis?

A. Administer IV antibiotics
B. Monitor blood pressure
C. Administer fluids
D. All of the above

Correct answer: D

Rationale: In the management of sepsis, prompt intervention is crucial. Administering IV antibiotics is essential to target the underlying infection. Monitoring blood pressure helps assess the patient's hemodynamic status. Administering fluids is vital to maintain adequate perfusion. Therefore, all the options are integral components of the initial management of sepsis, making 'All of the above' the correct answer. Choosing any single intervention over the others may delay optimal care and compromise patient outcomes.

5. A nurse is reinforcing teaching about using a cane with a client who has left-leg weakness. What instruction should the nurse give?

A. Use the cane on the weaker side
B. Advance the cane and the strong leg together
C. Maintain two points of support on the floor at all times
D. Advance the cane 30 to 45 cm with each step

Correct answer: C

Rationale: The correct instruction for a client with left-leg weakness using a cane is to maintain two points of support on the floor at all times. This technique provides stability and support while walking. Choice A is incorrect because the cane should be used on the stronger side to support the weaker leg. Choice B is incorrect as advancing the cane and the strong leg together may not provide adequate support and balance. Choice D is incorrect as the distance to advance the cane with each step can vary depending on the individual's needs and abilities.