The nurse is emptying an ileostomy pouch for a patient Which assessment finding will the nurse report immediately?
Continuous output from the stoma
Presence of blood in the stool
Malodorous Stool
Liquid consistency with hard stool particles
The Correct Answer is B
A. Continuous output from the stoma. Ileostomies typically have continuous liquid output, which is expected.
B. Presence of blood in the stool: Blood in the stool can indicate stomal irritation, ulceration, or bleeding from the intestines, which requires immediate medical attention.
C. Malodorous stool. While foul-smelling stool can suggest an issue (e.g., infection), it is not necessarily an emergency.
D. Liquid consistency with hard stool particles. Ileostomy output is expected to be liquid, and occasional solid particles may occur if certain foods are not fully digested.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Report a positive finding to the provider. A positive guaiac test indicates the presence of blood in the stool, which may suggest gastrointestinal bleeding, colorectal cancer, or other GI disorders. It must be reported for further evaluation.
B. Don sterile disposable gloves. Sterile gloves are not required. Clean gloves are sufficient because this is a non-sterile procedure.
C. Test the quality control section before testing the stool specimen. There is no quality control section on a fecal occult blood test. The test involves applying stool to a guaiac card and adding developer.
D. Apply liberal amounts of stool to the guaiac paper. Only a thin smear of stool is required; too much stool may interfere with accurate test results.
Correct Answer is B
Explanation
A. Rye. Rye contains gluten, which must be avoided in celiac disease.
B. Rice. Rice is gluten-free and safe for individuals with celiac disease.
C. Barley. Barley contains gluten and should be avoided.
D. Wheat. Wheat contains gluten and is a primary trigger for celiac symptoms.
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