The nurse is assessing the patient's output for the shift. What finding is most concerning?

Green, soft stool after the patient received antibiotics

Large, loose stool after the patient received a laxative

Dry, hard stool from a patient receiving opiates.

Black tarry stool from a patient receiving an anticoagulant

Answer and Explanation

The Correct Answer is D

A. Green, soft stool after the patient received antibiotics: Green stool can be a side effect of antibiotics due to changes in gut flora but is not typically concerning.

B. Large, loose stool after the patient received a laxative: This is an expected outcome of laxative use and is not cause for concern.

C. Dry, hard stool from a patient receiving opiates: Opiates commonly cause constipation. While this requires management, it is not the most concerning finding.

D. Black tarry stool from a patient receiving an anticoagulant: Black tarry stool (melena) indicates gastrointestinal bleeding, which can be life-threatening, especially in a patient on anticoagulants. Immediate assessment is required.

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Correct Answer is D

Explanation

A. 89-year-old with dementia and NG tube with continuous tube feeding: While this patient requires monitoring, continuous tube feeding is routine, and there is no indication of immediate distress.

B. 73-year-old with hypoactive bowel sounds one day post-cholecystectomy: Hypoactive bowel sounds are expected after surgery, particularly after abdominal procedures. This does not indicate an emergency.

C. 43-year-old with anorexia and nausea for two days who is tolerating a clear liquid diet: This patient’s condition is stable, and nausea is resolving, making them a lower priority.

D. 65-year-old who has dysphagia after suffering from a stroke who is NPO: Dysphagia (difficulty swallowing) increases the risk of aspiration pneumonia, which can be life-threatening. This patient should be assessed first to ensure their airway is protected.

A. Protective prone B. Left lateral recumbent C. High Fowler's D. Dorsal recumbent

Correct Answer is B

Explanation

A. Protective prone: The prone position (lying on the stomach) does not allow easy enema administration and is not recommended.

B. Left lateral recumbent: The left lateral position allows gravity to assist with enema administration and helps the fluid move efficiently through the colon.

C. High Fowler's: Sitting upright does not promote proper enema flow, making it ineffective.

D. Dorsal recumbent: Lying on the back does not facilitate enema administration effectively.

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Stoma Assessment	Stoma is protruding 2cm, is red and moist. Peristomal area is clean and intact.
Output	Liquid stool that is malodorous. Gas present in the appliance.
General Status	Patient is avoiding looking at the ileostomy during care.
Laboratory Data	Potassium 3.6 mEq/L (normal 3.5 to 5 mEq/L) Sodium 137 mEq/L (normal 135 to 145 mEq/L) Creatinine 0.9 mg/dL (normal 0.6 to 1.2 mg/dL)

The nurse is assessing the patient's output for the shift. What finding is most concerning?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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