A nurse is caring for a client who has an ileostomy.
Nurses' Notes
Day 1:
- Client is alert and oriented.
- ileostomy stoma is pink.
- Stoma draining moderate brown liquid stool.
- Client will not look at the stoma.
- Client states they are not interested in learning about stoma care.
- Intake: 2,200 mL over the last 24 hr
- Urine output: 1,200 ml over the last 24 hr
Day 2:
- ileostomy pouch changed. Skin surrounding the stoma is reddened and appears irritated
- initiated a request for a referral to an ostomy nurse.
- intake. 1,600 mL over the last 24 hr
- Urine output: 650 mL over the last 24 hr
The nurse is reviewing the client's medical record. Select the information that requires intervention by the nurse.
Ileostomy stoma is pink.
Stoma draining moderate brown liquid stool.
Client will not look at the stoma.
Client states they are not interested in learning about stoma care
Intake: 2,200 mL over the last 24 hr
Skin surrounding the stoma is reddened and appears iritated
Urine output: 650 mL over the last 24 hr
Correct Answer : F
f) Skin surrounding the stoma is reddened and appears irritated.
The information that requires intervention by the nurse is that the skin surrounding the stoma is reddened and appears irritated. This may indicate that the client is experiencing skin irritation or breakdown, which can lead to infection or other complications. The nurse should assess the skin and initiate appropriate interventions to prevent further skin damage.
Options a, b, c, d, e, and g do not necessarily require intervention by the nurse. A pink ileostomy stoma and moderate brown liquid stool drainage are normal findings. The client's refusal to look at the stoma or learn about stoma care may be concerning, but it is not an immediate priority for intervention. An intake of 2,200 mL over 24 hours and a urine output of 650 mL over 24 hours are within normal limits.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
The nurse should stop the transfusion, place the client in high-Fowler's position, obtain a prescription for a diuretic, and administer oxygen to the client. These actions can help manage the symptoms of transfusion- associated circulatory overload (TACO), which can occur when a client receives too much fluid too quickly during a blood transfusion.
c. Administering epinephrine is not an appropriate action for managing TACO. Epinephrine is used to treat anaphylaxis, which is a different type of transfusion reaction.
Correct Answer is C
Explanation
When using a two-wheeled walker, the client should stand with their elbows slightly flexed while holding the walker. This allows for proper posture and support while using the walker.
Option a is incorrect because stooping forward can cause strain on the back and neck.
Option b is incorrect because moving the walker too far ahead can cause instability and increase the risk of falls.
Option d is incorrect because picking up the walker with each step can cause fatigue and decrease the effectiveness of the walker.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today