A nurse is assisting in monitoring a client who is receiving a tube feeding. Which of the following findings should the nurse identify as the priority?

Temperature 38.2° C (100.8° F)

Hematocrit 45%

Respiratory rate 12/min

Urine specific gravity 1.015

Answer and Explanation

The Correct Answer is A

A.   This temperature is slightly elevated (normal range is typically around 36.5-37.5°C or 97.7-99.5°F). While a mild temperature elevation could indicate infection or other underlying issues, it may not be immediately critical unless accompanied by other symptoms such as chills, increased heart rate, or signs of respiratory distress.
B.   Hematocrit measures the proportion of red blood cells in the blood. A hematocrit of 45% is within the normal range for adults. However, changes in hematocrit levels over time can indicate fluid balance issues

or nutritional status, which are important to monitor but may not be an acute priority unless significantly abnormal.
C.   A respiratory rate of 12 breaths per minute is within the normal range for adults. However, it's essential to consider if this rate is stable or if there are signs of respiratory distress such as increased effort or decreased oxygen saturation. Respiratory status should always be closely monitored, but a normal rate alone is not a priority concern.
D.   Urine specific gravity measures the concentration of urine and can indicate hydration status. A specific gravity of 1.015 is within the normal range for urine concentration. However, changes in urine output or specific gravity can provide insights into fluid balance and renal function over time.

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Correct Answer is D

Explanation

A. There is no indication of an emergency based on black stools alone without other concerning symptoms such as severe abdominal pain, cramping, or signs of gastrointestinal bleeding.
B. While gathering more information about the client's diet may be helpful in some cases, it does not address the specific concern about the black stools related to iron supplementation.
C. Unless there are other concerning symptoms, such as gastrointestinal bleeding or significant discomfort, this situation does not typically warrant an immediate visit to the office. It can be managed with reassurance and education over the phone.
D. Iron supplements commonly cause stools to turn black due to the way iron is metabolized in the digestive system. This change in stool color is known as "iron-induced blackening." It occurs because iron supplements contain iron salts that undergo chemical reactions in the gastrointestinal tract, resulting in the production of iron sulfide compounds that impart a black color to the stool.

A. "I will be certain to take enteric-coated medications." B. "I will empty my pouch when it becomes one third full." C. "I will change my entire pouch system at least weekly." D. "I will use caution when eating high fiber foods."

Correct Answer is A

Explanation

A. Enteric-coated medications are designed to dissolve in the small intestine rather than the stomach. This is important for ileostomy patients because medications that dissolve in the stomach may be poorly absorbed or can cause irritation to the stoma or the small intestine.
B. It's recommended to empty the ostomy pouch when it's about one-third to half full to prevent leakage or discomfort.
C. How often the pouch system needs to be changed can vary depending on individual factors such as skin sensitivity, output consistency, and the type of pouch system used. Generally, changing the pouch system every 3-7 days is recommended.
D. High fiber foods can increase stool output and gas production, which can be challenging for individuals with an ileostomy. However, fiber is important for overall digestive health, so moderation rather than avoidance is typically recommended.

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A nurse is assisting in monitoring a client who is receiving a tube feeding. Which of the following findings should the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is speaking on the phone to a client on the phone who is pregnant and taking iron supplements for iron-deficiency anemia. The client reports that her stools are black but she has no abdominal pain or cramping. Which of the following responses by the nurse is appropriate?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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