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 ["740"]
Explanation
-
4 oz juice → 120 mL
-
6 oz tea → 180 mL
-
100 mL ice chips → 50 mL (Ice chips are counted as half their volume when melted)
-
IV bolus → 150 mL
-
8 oz broth → 240 mL
Total intake:
120+180+50+150+240=740mL120 + 180 + 50 + 150 + 240=740mL
Correct answer: 740 mL
Correct Answer is B
Explanation
A. Uremia is a buildup of waste products in the blood due to kidney failure, leading to confusion, nausea, and other systemic symptoms rather than acute urinary incontinence.
B. Cystitis (bladder infection) causes inflammation, urgency, frequency, dysuria, and can lead to sudden incontinence in older adults, particularly those with weakened immune systems or cognitive impairment.
C. Diverticulitis is an inflammation of the colon’s diverticula, leading to abdominal pain and bowel disturbances, not urinary incontinence.
D. Nephrosclerosis is a chronic condition involving kidney damage due to hypertension or diabetes, which may lead to kidney failure but does not directly cause acute urinary incontinence.
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