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. "Void every four hours even if you feel like you do not need to urinate." While frequent voiding is beneficial, forcing a rigid schedule is not necessary. The priority is voiding after intercourse and staying hydrated to flush bacteria.

B. "You should perform Kegel exercises several times a day." Kegel exercises strengthen the pelvic floor but do not prevent UTIs.

C. "When possible, you should try to take a tub bath instead of a shower." Soaking in a bath can introduce bacteria into the urethra, increasing UTI risk. Showers are recommended.

D. “It is important to clean front to back during bathing and after using the restroom.” Wiping front to back prevents the spread of bacteria from the perineal area to the urethra, a major cause of UTIs.

A. Powered stand assist B. Cane C. Gait belt D. Four wheel walker

Correct Answer is C

Explanation

A. Powered stand assist: Powered stand assist devices are used for clients who cannot bear weight independently, not for balance issues during ambulation.

B. Cane: A cane provides minimal support and is best for clients with mild weakness, not for those with frequent balance loss.

C. Gait belt: A gait belt provides stability and support while allowing the nurse to assist the client safely if they begin to lose balance.

D. Four-wheel walker: A four-wheel walker rolls easily, which may increase fall risk in a client with balance issues. A standard walker (without wheels) would be safer in some cases.

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

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