A nurse is assessing a client who has a colostomy and notices that the stoma is pale in color. Which of the following findings should the nurse report to the provider?

The skin around the stoma is red.

The ostomy is draining frequently.

The stool is yellow-green.

The stoma is moist and pink.

Answer and Explanation

The Correct Answer is A

A pale stoma can indicate poor blood flow, which is a serious concern that should be reported to the provider immediately. A healthy stoma should be moist and dark red or pink in color.

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Correct Answer is B

Explanation

Choice A rationale

Constipation is not typically resolved by diluting enteral feeding formula.

Choice B rationale

Diarrhea can be a common side effect of enteral feeding, and diluting the formula can help manage this.

Choice C rationale

While electrolyte imbalance can occur with enteral feeding, diluting the formula is not typically done to resolve this issue.

Choice D rationale

Delayed gastric emptying is not typically resolved by diluting enteral feeding formula.

Correct Answer is ["125"]

Explanation

Step 1 is to understand the question. The patient has been prescribed vancomycin 1 g in 250 mL dextrose 5% (D5W) to be administered over 2 hours via IV intermittent bolus. We need to calculate how many mL/hr the nurse should set the IV pump to deliver.

Step 2 is to calculate the rate. The total volume to be administered is 250 mL and the time for administration is 2 hours. So, the rate is 250 mL ÷ 2 hours = 125 mL/hr.

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A nurse is assessing a client who has a colostomy and notices that the stoma is pale in color. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who is receiving enteral tube feeding and has a new prescription to dilute the formula. The nurse recognizes this is being done to resolve which of the following conditions?

Correct Answer is B

Explanation

A nurse is caring for a patient who has sepsis. The patient has been prescribed vancomycin 1 g in 250 mL dextrose 5% (D5W) to be administered over 2 hours via IV intermittent bolus. How many mL/hr should the nurse set the IV pump to deliver?

Correct Answer is ["125"]

Explanation

A nurse is developing a care plan for a patient with a decreased level of consciousness who is receiving continuous enteral feedings through a gastrostomy tube due to an inability to swallow.What should be the nurse’s priority action?

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