A client who has been caring for an ostomy on the left side of the abdomen for several years is admitted to the hospital. Which type of stool can the nurse expect?

Moist and formed

Ribbon like

Mucus coated

Loose and liquid

Answer and Explanation

The Correct Answer is A

A. Moist and formed: A left-sided ostomy is likely from the descending or sigmoid colon, where stool is more formed and solid because most water has been absorbed.

B. Ribbon-like: Ribbon-like stool is often associated with bowel obstruction or colorectal cancer, not a normal ostomy output.

C. Mucus-coated: Mucus-coated stool is more typical in patients with an ileostomy or colitis, not a long-term colostomy.

D. Loose and liquid: Liquid stool is expected with an ileostomy (right-sided ostomy), where less water is absorbed.

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Correct Answer is B

Explanation

A. Decrease in the respiratory rate from 20 to 16/min: Hypovolemic shock typically causes tachypnea (increased respiratory rate) as the body tries to increase oxygen delivery. A decreasing respiratory rate is not an expected finding.

B. Increase in the heart rate from 88 to 110/min: Tachycardia is an early sign of hypovolemic shock because the heart compensates for low blood volume by pumping faster.

C. Decrease in the urinary output from 50 mL to 30 mL per hour: A drop in urine output suggests early organ perfusion issues, but hypovolemic shock is suspected when urine output falls below 20 mL/hr.

D. Increase in the temperature from 99.5°F to 101.5°F: Fever suggests infection or inflammatory response, not hypovolemic shock. Shock typically causes hypothermia (low body temperature) as circulation is compromised.

A. Avoid drawing blood from the affected extremity B. Auscultate the fistula for the sound of a bruit C. Palpate the site to identify the presence of a thrill D. Irrigate the fistula with saline to maintain patency E. Keep the fistula clamped until ready to perform dialysis

Correct Answer is ["A","B","C"]

Explanation

A. Avoid drawing blood from the affected extremity: Blood draws, IVs, and BP measurements should never be done on the fistula arm to prevent damage and thrombosis.

B. Auscultate the fistula for the sound of a bruit: A bruit (whooshing sound) confirms blood flow through the fistula, indicating patency.

C. Palpate the site to identify the presence of a thrill: A thrill (vibration) should be felt over the fistula. Absence may indicate clotting or failure.

D. Irrigate the fistula with saline to maintain patency: A fistula is never irrigated. Only dialysis staff should access it.

E. Keep the fistula clamped until ready to perform dialysis: AV fistulas are not clamped. Clamping could obstruct blood flow.

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A client who has been caring for an ostomy on the left side of the abdomen for several years is admitted to the hospital. Which type of stool can the nurse expect?

Nursing Test Bank

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