ATI Ns 117 Fundamentals Exam | Nurselytic

Questions 38

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ATI Ns 117 Fundamentals Exam Questions

Extract:

Nurses’ Notes
Day 1:

Abdomen soft, nondistended.
Ileostomy present. Stoma is red.
Stoma draining brown liquid stool.
Client will not look at stoma
Client states they are not interested in learning about stoma care.
Day 2:

Ileostomy pouch changed. Skin surrounding stoma is reddened and has small open areas.


Question 1 of 5

A nurse is assisting in the care of a light-skinned client who has an ileostomy Exhibits:The nurse is reviewing the client's medical record.Select all the findings that require intervention by the nurse.

Correct Answer: A,B,C

Rationale:
Correct
Answer: A,B,C


Rationale:
A: Client will not look at stoma - This finding requires intervention as the client needs to be educated on stoma care and should be encouraged to participate in self-care.
B: Client states they are not interested in learning about stoma care - This indicates a lack of understanding or denial, requiring the nurse to provide education and support to ensure proper care.
C: Skin surrounding stoma is reddened and has small open areas - This suggests skin breakdown and potential infection, necessitating immediate intervention to prevent further complications.

Summary:
D: Ileostomy present. Stoma is red - This is a normal finding for an ileostomy and does not require immediate intervention.
E: Stoma draining brown liquid stool - This is a normal finding for an ileostomy and does not require immediate intervention.
F: Abdomen soft, nondistended - This is a normal assessment finding and does not require immediate intervention in this context.

Extract:


Question 2 of 5

Correct Answer:

Rationale:

Question 3 of 5

Correct Answer:

Rationale:

Question 4 of 5

Correct Answer:

Rationale:

Question 5 of 5

Correct Answer:

Rationale:

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