Fundamentals Exam B- ATI

A nurse is caring for a client who has a prescription for 5 units of regular insulin and 10 units of NPH insulin to mix together and administer subcutaneously. determine the correct order of steps for this procedure 1.inject 5 units of air into the bottle of regular insulin 2. inject 10 units of air into the bottle of regular insulin 3.withdraw the correct dose of regular insulin from the bottle 4. withdraw the correct dose of nph insulin from the bottle

2, 1, 3, 4

A nurse is performing a peripheral vascular assessment for a client. When placing the bell of the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following?

Narrowed arterial lumen (hearing bruits on the audiotape indicates that blood flowing through the occluded or narrowed arteriesHeart Soundshttps://www.youtube.com/watch?v=6YY3OOPmUDA

A nurse is reviewing protocol in preparation for suctioning secretions from a client who has a new tracheostomy. Which of the following actions should the nurse place to take? A. Use a resuscitation bag with 80 oxygen prior to the procedure B. Select a suction catheter that is half the size of the lumen C. Place the end of the suction catheter in water- soluble lubricant D. Adjust the wall suction apparatus to a pressure of 170 mm Hg

B. Select a suction catheter that is half the size of the lumen The nurse should select a suction catheter that is half the size of the lumen to prevent hypoxemia and trauma to the mucosa.

A nurse in an acute facility is preparing discharge summary for a client who is transferring to a long-term care facility. Which of the following documentation should the nurse include? A. Client flow sheet B. Acuity ratings C. Current medications D. Incident reports

C. Current medications The nurse should include the client's medications in the discharge summary to ensure client safety and continuity of care.

A nurse is preparing to obtain a lower extremity BP from a client and no linger palpates the popliteal pulse aftewr 92 mm HG. Which of the following images displays the measurement in mm HG to which the nurse should inflate the cuff when obtaining BP A.82 B. 102 C. 112 D. 122

D. 122 To obtain an accurate blood pressure measurement, the nurse should inflate the cuff 30 mm Hg beyond the point at which the nurse was last able to palpate the pulse. If the nurse last palpated the pulse at 92 mm Hg, then this would be the correct pressure to which the nurse should inflate the cuff.

A nurse is caring for a client who has decreased mobility. Which of the following actions should the nurse take to decrease the client's risk of developing plantar flexion contractures? A. Place pillow under client's knees B. Position a trochanter roll under each of the client's hips C. Advise the client to wear rubber- soled slippers D. Apply an ankle foot orthotic device to the client's feet

D. Apply an ankle foot orthotic device to the client's feet

A nurse is planning care for a client who has a vision loss. Which of the following interventions should the nurse include in the plan of care to assist the client with feeding? A. Assign a staff member to feed the client B. Provide small-handled utensils for the client C. Thicken liquids on the clients tray. D. Arrange food in a consistent pattern on the clients plate.

D. Arrange food in a consistent pattern on the clients plate. Consistency in preparing the client's plate helps to facilitate self-feeding for clients who have vision loss. Staff can describe the location of the food on the plate by using a clock pattern, allowing the client to have greater independence during meals.

A nurse is caring for a client who reports pain. When documenting the quality of the clients pain on an initial pain assessment, the nurse should record whaich of the following client statments? A. Im having mild pain B. The pain is like a dull ache in my stomach C. I notice that the pain gets worst after I eat. D. The pain makes me feel nauseous

B. The pain is like a dull ache in my stomach The client is describing the quality of the pain, which is how the pain feels in the client's own words.

A nurse is caring for a group of clients on a medical-surgical unit. In which of the following situations does the nurse demonstrate the ethical principle of veracity? A. A client who is unaware of her recent cancer diagnosis ask the nurse if she has cancer, and the nurse responds affirmatively B. A client who has a prescription for a NG tube refuses it, and the nurse complies with the client's wishes C. A client who has a DNR order has a cardiac arrest, and the nurse does not perform CPR despite requests from the client's family D. A client who is about to undergo a painful procedure receives pain medicaiton 30 mins before the procedure that the nurse previously promised to adminster

A. A client who is unaware of her recent cancer diagnosis ask the nurse if she has cancer, and the nurse responds affirmatively Following the ethical principle of veracity, the nurse must tell the truth at all times and never deceive others.

A nurse is administering IV fluids to a client. When monitoring for adverse effects. Which of the following assessments should the nurse identify as the priority? A. Auscultate lung sounds B. Measure Urine output C. Monitor BP reading D. Monitor electrolyte levels

A. Auscultate lung sounds The priority assessment the nurse should make when using the airway, breathing, circulation approach to client care is auscultating lung sounds to monitor for fluid volume excess, a complication of IV therapy. Manifestations of fluid volume excess include moist crackles in lung fields, dyspnea, and shortness of breath.

A nurse is preparing to administer 0.5mL of oral single-dose liquid medication to a client. Which of the following actions should the nurse take? A. Gently shake the continer of medicaiton prior to administration B. Transfer the medication to a medicine cup C. Place the client in a semi-fowlers position to mediction administration D. Verify the doseage by measuring the liquid before administering it.

A. Gently shake the continer of medicaiton prior to administration

A charge nurse is observing a newly licensed nurse prepare a sterile field for a dressing change. Which of the following action by the newly licensed nurse requires intervention by the charge nurse? A. The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field B. The newly licensed nurse places sterile objections 2.5 cm (1 in) within the border of the field. C. The newly licensed nurse hold the bottle of sterile saline outside the edge of the field when pouring D. The sterile field is positioned at the level of a newly licensed nurses waist.

A. The newly licensed nurse places the cap of a bottle of sterile saline solution on the sterile field The newly licensed nurse should place the cap with the sterile side up on a clean surface because the outer edges are unsterile and will contaminate the sterile field.

A nurse is teaching an older adult client who is at risk for osteoporosis about beginning a program of regular physical activity. Which of the following types of activity should the nurse recommend? A. Walking briskly B. Riding a bicycle C. Performing isometric exercises D. Engaging in high- impacts aerobics.

A. Walking briskly Weight-bearing exercises are essential for maintaining bone mass, which helps to prevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy.

A nursing is teaching a client whose left leg is in a cast about using crutches. Which of the following statements should the nurse identify as an indication that the client understands the teaching? A. When descending stairs, I will first shift my weight to my right leg. B. I should place my crutches 12 ins in front and to the side if each foot. C. As I sit down, I will hold one crutch in each hand D. I will make sure the shoulder rests are snug against my armpits.

A. When descending stairs, I will first shift my weight to my right leg. To descend stairs, the client should first shift his body weight to his right, unaffected leg.

A nurse is admitting a client. Exhibit 1 Nurses' Notes 0930:Client reports a sore throat, productive cough, shortness of breath, and fever for the past 4 days.1030:Client has swollen lymph nodes of the neck upon palpation. Client reports chills and coughs up yellow-colored mucus. Client's face is flushed and diaphoretic. States lack of appetite. Chest x-ray obtained and positive for pneumonia. Exhibit 2 Vital Signs 1030:Blood pressure 110/68 mm HgHeart rate 110/minRespiratory rate 24/minTemperature 38.6° C (101.5° F)Oxygen saturation 91% on room air

Place the client on droplet isolation precautions is correct. The nurse should identify that the client has pneumonia, which is transmitted through droplets greater than 5 microns in the air. Therefore, the nurse should place the client on droplet isolation precautions. Apply oxygen at 2 L/min via nasal cannula is correct. The nurse should identify that the client's oxygen saturation is less than 95% on room air, indicating a decrease in oxygen in the client's blood, which can lead to hypoxia. Therefore, the nurse should apply oxygen at 2 L/min via nasal cannula to the client. Request a prescription for an antipyretic medication is correct. The nurse should identify that the client has a temperature of 36.6° C (101.5° F), indicating a fever. Therefore, the nurse should request an antipyretic medication to treat the client's fever. Wear an N-95 mask when providing care to the client is incorrect. The nurse should wear an N-95 mask when providing care to clients who have an airborne infection and are in a negative air pressure room. Request a prescription for an antihypertensive medication is incorrect. The client's blood pressure is within the expected reference range. Therefore, a request for a prescription for an antihypertensive medication is not indicated. Remain 1 m (3 feet) from the client is correct. The nurse should identify that the client has pneumonia. Therefore, the nurse should wear a sterile mask and remain within 1 m (3 feet) from the client.

A nurse is caring for a client who has a pressure injury. Exhibit 1 Nurses' Notes Day 1:Client is alert and oriented to person, place, and time. Client has stage 2 pressure injury on coccyx. Wound tissue is pink with no drainage. Lungs clear on auscultation. Heart sounds are regular. +2 peripheral pulses and no presence of edema in lower extremities. Bowel sounds active x 4 quadrants. Client ate 50% of breakfast. Client reports pain to pressure injury as 2 on a scale of 0 to 10. Client repositioned every 2 hr while in bed.Day 4:Client has stage 2 pressure injury on coccyx. Wound tissue is yellow with purulent drainage. Wound has foul odor. Client ate 75% of breakfast. Client reports pain to pressure injury as 6 on a scale of 0 to 10. Client repositioned every 2 hr while in bed. Exhibit 2 Vital Signs Day 4:Temperature 38.3° C (101° F)Pulse rate 80/minRespiratory rate 20/minBlood pressure 128/64 mm HgOxygen saturation 93% on room air Exhibit 3 Diagnostic Results Day 4:Potassium 4.2 mEq/L (3.5 to 5 mEq/L)Hgb 13 g/dL (12 to 16 g/dL)Hct 38% (37% to 47%)WBC count 12,000/mm3 (5,000 to 10,000/mm3)Prealbumin12 mg/dL (15 to 36 mg/dL Click to highlight the findings that the nurse should report to the provider. To deselect a finding, click on the finding again. Temperature WBC count Prealbumin level Hemoglobin level Blood pressure Pain level Odor of wound Bowel sounds

Temperature is correct. The nurse should identify that the client has a fever, which is a manifestation of an infection. Therefore, the nurse should report this finding to the provider. WBC count is correct. The nurse should identify that the client has a WBC count that is greater than the expected reference range, which is a manifestation of an infection. Therefore, the nurse should report this finding to the provider. Prealbumin level is correct. The nurse should identify that the client has a prealbumin level that is lower than the expected reference range. This is a manifestation of malnutrition, which contributes to delayed wound healing. Therefore, the nurse should report this finding to the provider. Pain level is correct. The nurse should identify that the client's pain level has increased over 3 days and is an indication of complications associated with wound healing. Therefore, the nurse should report this finding to the provider. Odor of wound is correct. The nurse should identify that a foul odor of a wound is a manifestation of an infection. Therefore, the nurse should report this finding to the provider.

A nurse is preparing a heparin infusion for a client who was admitted to the facility with DVT. The presciption reads:25,000 units of heparin in 0.9% sodium cloride 250ml to infuse at 800 units/hr. At what rate should the nurse set the infistion pump?

8 mL/hr Follow these steps for the Ratio and Proportion method of calculation: Step 1: What is the unit of measurement the nurse should calculate? mL/hr Step 2: What is the dose the nurse should administer? Dose to administer = Desired 800 units/hr Step 3: What is the dose available? Dose available = Have 25,000 units Step 4: Should the nurse convert the units of measurement? No Step 5: What is the quantity of the dose available? 250 mL Step 6: Set up an equation and solve for X. HaveDesired = QuantityX 25,000 units800 units/hr = 250 mLX mL X mL/hr = 8 mL/hr Step 7: Round if necessary. Step 8: Determine whether the amount to administer makes sense. If there are 25,000 units/250 mL and the prescription reads 800 units/hr, it makes sense to administer 8 mL/hr. The nurse should set the infusion pump to administer 8 mL/hr.

A nurse in the emergency department (ED) is caring for a client who reports abdominal pain. Exhibit 1 Nurses' Notes 1200:Client arrives to ED and reports abdominal pain and no bowel movement for the past 7 days. Client is undergoing chemotherapy for pancreatic cancer and has been taking 40 mg oxycodone extended-release tablets daily for the past 3 months. Client states they have attempted to relieve constipation for the last 7 days with bisacodyl suppositories and magnesium citrate oral suspension. Client reports that neither therapy initiated defecation.1230:Client transported for abdominal x-ray.1245:Client returned from x-ray. Provider prescribes a hypertonic cleansing enema.1300:Procedure explained to client who verbalized understanding. Exhibit 2 Diagnostic Results 1245:Abdominal x-ray indicates a large amount of fecal material throughout the colon. No evidence of gastrointestinal obstruction observed. Based on the clients clinical findings which of the following actions should the nurse take? Select all that apply. Assist the client to left side-lying postion with the right knee flexed Prepare the client for a chest x-ray Administer a cleansing enema Auscultate the clients bowel sounds Perform a manual digital examination of a clients rectum Adminster oxycodone extended release tabs Prepare the client for NG tube placement

Assist the client to a left side-lying position with the right knee flexed is correct. The nurse should place the client in a left side-lying position with the right knee flexed prior to administering an enema. Because the provider prescribed a cleansing enema for the client, the nurse should prepare the client for the procedure. Prepare the client for a chest x-ray is incorrect. A chest x-ray is typically performed for a client who has an impairment of the upper thorax or lungs, not the abdomen. The client has already received an abdominal x-ray; therefore, a chest x-ray is not necessary. Administer a cleansing enema is correct. The nurse should administer a cleansing enema for the client as a result of the provider's prescription. A cleansing enema is intended to assist with bowel elimination and remove any impacted fecal matter indicated by the abdominal x-ray. Auscultate the client's bowel sounds is correct. The nurse should auscultate the client's bowel sounds to determine the status of the client's peristalsis. This is a necessary part of determining the presence of bowel sounds, which are an indication of the status of the client's gastrointestinal tract. Perform a manual digital examination of the client's rectum is correct. The nurse should perform a manual digital examination of the client's rectum to determine if impacted stool is present. This is a part of the necessary evaluation of the status of the client's gastrointestinal tract. Administer oxycodone extended-release tablets is incorrect. Although the client has a prescription for oxycodone to treat pain related to pancreatic cancer, opioid medications can cause the adverse effect of constipation. Because the client reports not having experienced a bowel movement for an extended period of time, the nurse should withhold further opioids until the cause of the client's constipation is determined. Prepare the client for NG tube placement is incorrect. The nurse should not prepare the client for placement of an NG tube because there is no indication or prescription to do so. Placement of an NG tube is required when there is an obstruction of the gastrointestinal tract and peristalsis is absent.

A nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. In preparation for the client's procedure, which of the following precautions should the nurse take? A. Ensure sterilization of nondisposable items with ethylene oxide B. Wrap the monitoring cord with a stockinette and tape them in place. C. Cleanse latex ports on IV tubing with chlorhexidine before injecting medications D. Wear hypoallergenic latex gloves that contain powder.

B. Wrap the monitoring cord with a stockinette and tape them in place. Many monitoring devices and cords contain latex. The nurse should prevent any contact of these cords and devices with the client's skin by covering them with a nonlatex barrier material, such as stockinette, and using nonlatex tape to secure them.

A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe enviorment, which of the following actions should the nurse take next? A. Rock the client up to a standing position B. Pivot on the foot that is the farthest from the chair C. Assess the client for orthostatic hypotension D. Apply a gait belt to the client

C. Assess the client for orthostatic hypotension The first action the nurse should take when using the nursing process is to assess the client. The nurse should determine the client's risk for falling or fainting during the transfer by assisting the client to sit and dangle the feet on the side of the bed. The nurse should assess for dizziness and a significant drop in blood pressure before assisting the client to stand and transfer into the chair.

A nurse is performing a Romberg test during the physical assessment of a client. Which is the following techniques should the nurse use? A. Touch the face with cotton ball B. Apply a vibrating tuning fork to the clients forehead C. Have the client stand with their arms at their sides and their feet together D. Perform direct percussion over the area of the kidneys.

C. Have the client stand with their arms at their sides and their feet together A Romberg test helps identify alterations in balance. The nurse should have the client stand with their arms at their sides and their feet together to observe for swaying and a loss of balance.

A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the clients indicates an understanding of the the teaching? A. I had a bowl movement, but I was able to save the urine B. I have a specimen in the bathroom from about 30 mins ago C. I flushed what I urinated at 7am and have saved all urine since. D. I drink alot, so I will fill up the bottle and complete the test quickly

C. I flushed what I urinated at 7am and have saved all urine since. For a 24-hr urine collection, the client should discard the first voiding and save all subsequent voidings.

A nurse is reviewing a client's medication prescription that reads, " digoxin 0.25 by mouth everyday". Which of the following compinets of the prescribtion should the nurse verify with the provider? A. Medicaiton name B. Route of administration C. Medication Dose D. Frquency of administration

C. Medication Dose In the prescription, the medication dose is not complete. The number 0.25 should be followed by a unit of measurement, such as mg, to clarify the amount the nurse should administer.

A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect. A. Neck vein distention B. Urine specific gravity 1.010 C. Rapid heart rate D. BP 144/82

C. Rapid heart rate Tachycardia indicates fluid volume deficit, which is an expected finding for a client who has had vomiting and diarrhea for 3 days.

A nurse in the emergency department (ED) is caring for a client. Exhibit 1 Nurses' Notes 1100:Client arrives to ED and reports nausea, vomiting, and diarrhea for 3 days. Client is febrile.1110:Provider at bedside; prescriptions received.1115:IV initiated to right arm with 20-gauge catheter. Acetaminophen and metoclopramide administered.1200:Client appears fatigued, with no energy. Hair is thin and sparse. Cachectic, with flaccid muscle tone. Oriented x 3, able to move all extremities. Tachycardia, edema to lower extremities. Respirations unlabored, chest clear. Bowel sounds x 4 hyperactive, abdomen distended. Reports no difficulty with urination. Skin dry and scaly with bruises on extremities. Exhibit 2 Medication Administration Record 1115:Acetaminophen 650 mg rectal every 6 hr PRN temperature greater than 38.3° C (101° F)Metoclopramide 10 mg IV every 6 hr PRN nausea/vomiting Exhibit 3 Vital Signs 1100:Temperature 39.2° C (102.6° F)Pulse rate 118/minRespiratory rate 18/minBlood pressure 92/68 mm HgOxygen saturation 95%Weight 44.9 kg (99 lb)BMI 17 Click to highlight the findings that indicate the client is malnourished. To deselect a finding, click on the finding again. Cachectic, with flaccid muscle tone. Skin dry and scaly with bruises on extremities. Oriented x 3, able to move all extremities. Pulse rate 118/min Respiratory rate 18/min Abdomen distended Temperature 39.2° C (102.6° F) BMI 17

Cachectic, with flaccid muscle tone is correct. The client's lack of energy, flaccid muscle tone, and wasting appearance can be an indication of malnutrition. Skin dry and scaly with bruises on extremities is correct. The client's dry, scaly, and bruised skin can be an indication of malnutrition. Oriented x 3, able to move all extremities is incorrect. The client's neurological status is within expected parameters. Pulse rate 118/min is correct. The client's tachycardia can be an indication of malnutrition. Respiratory rate 18/min is incorrect. The client's respiratory rate is within the expected reference range. Abdomen distended is correct. The client's abdominal distention can be an indication of malnutrition. Temperature 39.2° C (102.6° F) is incorrect. An elevated temperature is not an indication of malnutrition. BMI 17 is correct. A BMI of 17 is considered underweight and can be an indication of malnutrition.

A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse provide to the client and his family? Select all that apply Check the cold routinely for frays or tearing Keep the unit at least 1.2 m (4 ft) away from a gas stove Consider purchasing a generator for power back up Observe for signs of hypoxia Select synthetic clothing and bedding

Check the cord routinely for frays or tearing is correct. Oxygen concentrators require electrical power. Safe use of this delivery system includes assessing the electrical function of the device; therefore, the nurse should instruct the client to routinely check the condition of the cord.Keep the unit at least 1.2 m (4 feet) away from a gas stove is incorrect. Safe use of home oxygen equipment includes keeping the unit at least 3.05 m (10 feet) away from open flames, such as from a fireplace or a gas stove, and at least 2.4 m (8 feet) away from other heat sources.Consider purchasing a generator for power backup is correct. Loss of electricity prevents the oxygen concentrator from functioning and could deprive the client of necessary oxygen. The nurse should also instruct the family to have the client placed on their municipality's priority list for restoring power after an outage occurs.Observe for signs of hypoxia is correct. The nurse should instruct the family to observe for and report signs of hypoxia, such as anxiety, worsening fatigue, dizziness, rapid pulse and respirations, pallor, and cyanosis. Even with supplemental oxygen, the client's status can worsen, resulting in the development of hypoxia.Select synthetic clothing and bedding is incorrect. Safe use of oxygen therapy includes choosing clothing and bedding made from material that does not generate static electricity; therefore, the nurse should instruct the client to select materials made from cotton.

A nurse is teaching a group of staff nurses about the use of essential oils for aromatherapy. The nurse should inclue in the teaching that this theray might be contraindicated for what of the following clients? A. A client whho has a history if physical abuse B. A client who has a permanent pacemarker C. A client who has ulcerative colitis D. A client who has asthma

D A client who has asthma Some essential oils can cause bronchospasm; therefore, the nurse should consult the client's provider before using this therapy for a client who has asthma.

A nursing is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice? A. Insert an implanted port B Close a laceration with sutures C. Place an enotracheal tube D. Initiate an enteral feeding through a gastrostomy tube

D. Initiate an enteral feeding through a gastrostomy tube It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes.

A middle adult client tells the nuse, " I feel so useless not that my children do not need me anymore" Which of the following reponses shoiuld the nurse make? A. Most people are happy when their children grow up and leave home B. You should be proud that your children are becoming independent C. Maybe you should consider why you are feeling useless D. People in the middle adulthood often find satisfaction in nurturinjg and guiding young people

D. People in the middle adulthood often find satisfaction in nurturinjg and guiding young people According to Erik Erikson, the task of middle adulthood is generativity versus self-absorption and stagnation. The focus of this task is on offering support and guidance to future generations. The nurse should explore opportunities for mastering the developmental tasks of this stage with the client, such as volunteering and mentoring young people.

A home health nurs is completing an admission assessment of an older adult client who has their caregiver present. Which of the following findings should the nurse identify as potential indiction of elder abuse? A. The caregiver is the client's finanical POA B. The client is in a wheelchair with the wheels locked C. The client reports recienving a full bath twice a week D. The caregiver insist on remaining in the room

D. The caregiver intsist on remaining in the room A caregiver who refuses to leave the room during an admission assessment can be an indication of potential mistreatment of the client who is receiving care. The nurse should evaluate the client for additional signs of potential mistreatment throughout the admission assessment.

A nurse in a medical-surgical unit is caring for six clients. Exhibit 1 Nurses' Notes​ 0800:Client 1: Client is admitted with a new diagnosis of rheumatoid arthritis.Client 2: Client has a history of hyperlipidemia. Atorvastatin 20 mg PO administered as prescribed.Client 3: Client is 1 day postoperative. Reports pain as 8 on a scale of 0 to 10. Morphine 5 mg subcutaneous administered as prescribed.Client 4: Client is admitted with a new diagnosis of heart failure.Client 5: Client has a stage 2 pressure injury on the left heel.Client 6: Client is admitted with a new diagnosis of diabetes mellitus. Exhibit 2 Diagnostic Results​ 0900:Client 1: C-reactive protein 3.2 mg/dL (less than 1.0 mg/dL)Client 2: Cholesterol 250 mg/dL (less than 200 mg/dL)Client 3: Oxygen saturation 88% (95% to 100%)Client 4: Potassium 3.2 mEq/L (3.5 to 5.0 mEq/L)Client 5: Prealbumin 14 mg/dL (15 to 36 mg/dL)Client 6: Glycosylated hemoglobin 8% (less than 7%)

The first client the nurse should assess is client 3 followed by client 4 Client 3 is correct. When using the airway, breathing, circulation approach to client care, the nurse should determine that this client is the priority client to assess. The client has an oxygen saturation that is less than the expected reference range, which is an indication of hypoxia. Client 4 is correct. When using the airway, breathing, circulation approach to client care, the nurse should determine that this client is the next priority client to assess. The client has a potassium level that is less than the expected reference range, which places the client at risk for dysrhythmias.

A nurse is caring for a client who has a newly placed ileostomy. Exhibit 1 Nurses' Notes 0800:Client is 2 days postoperative following an ileostomy. Pouch is one-fourth full of stool. Stoma is red. Abdomen is soft and nontender. Bowel sounds present in all quadrants. 1200:Stoma site appears dark purple with blistering on the skin around the stoma. Pouch is slightly leaking and is three-fourths full of brown, liquid stool. Exhibit 2 Diagnostic Results 1200:Hgb 19 g/dL (12 to 16 g/dL)Hct 46% (37% to 47%). Complete the following sentences by using the list of options

The nurse should first address the STOMA COLOR followed by the SKIN AROUND THE STOMA