ATI RN
ATI RN Fundamental Proctored Exam With NGN Graded Questions
Extract:
Question 1 of 5
The skin barrier covering a client's intestinal fistula keeps falling off when she stands up to ambulate. The nurse has reapplied it twice during the shift, but it remains intact only when the client is supine in bed. The nurse telephoned the physical therapist about the difficulties containing the drainage from the fistula, so the therapist didn't ambulate the client today. The client sat in a chair during lunch w/an absorbent pad over the fistula. The client ate all the food on her tray. The wound care nurse confirmed that she will see the client later today. The client states she feels frustrated at not having physical therapy, but the nurse thinks the client welcomed having a day to rest. Which of the following information should the nurse include in the change-of-shift report? Select all.
Correct Answer: A, B, D
Rationale: The correct choices to include in the change-of-shift report are A, B, and D.
Choice A is important to communicate as it highlights that the physical therapist did not ambulate the client due to difficulties with the skin barrier and fistula drainage.
Choice B is crucial as it explains the specific issue with the skin barrier, emphasizing that it stays intact when the client is supine but loosens when standing.
Choice D is essential to include as it informs about the upcoming visit from the wound care nurse.
Choices C and E, although relevant to the client's well-being, are not directly related to the current care plan and should not be included in the report.
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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