The nurse is emptying an ileostomy pouch for a patient. Which assessment finding would the nurse report immediately?

Liquid consistency of stool

Unpleasant odor from the stool

Presence of blood in the stool

Continuous output from the stoma

Answer and Explanation

The Correct Answer is C

Choice A For an ileostomy, liquid consistency of stool is expected as the output, and it is not an immediate concern.

Choice B Foul odor from the stool is common with ileostomy output, and while it can be unpleasant, it is not an immediate concern.

Choice C This finding should be reported immediately, as it could indicate bleeding from the stoma or intestinal mucosa, which requires prompt evaluation and intervention.

Choice D Continuous output from an ileostomy is normal and expected, so it is not a cause for immediate concern.

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Correct Answer is A

Explanation

Choice A Turnips are known to increase colostomy odors, as certain sulfurcontaining compounds present in turnips can produce a strong odor in the stool.

Choice B Beets may cause the stool to have a reddish appearance, but they are not specifically associated with increased colostomy odors.

Choice C Buttermilk is not typically associated with increased colostomy odors. Choice D Yogurt is not typically associated with increased colostomy odors.

A. The patient with a pale blue stoma B. The patient with a continuous draining stoma C. The patient with a stoma that had fecal contents all over it. D. The patient with a beefy red, moist stoma

Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale: A pale blue stoma indicates compromised perfusion or necrosis. This is a surgical emergency requiring immediate assessment to prevent tissue death and systemic complications.

Choice B rationale: Continuous drainage may reflect normal output depending on stoma type. It’s not immediately life-threatening and doesn’t require urgent intervention.

Choice C rationale: Fecal contamination is expected with colostomies. While hygiene is important, this does not indicate a critical issue needing priority care.

Choice D rationale: A beefy red, moist stoma is the expected healthy appearance of a functioning colostomy. No intervention is needed.

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The nurse is emptying an ileostomy pouch for a patient. Which assessment finding would the nurse report immediately?

Nursing Test Bank

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