The nurse is in the G unit is assessing a patient after receiving the change of shift SBAR report. What assessment findings will the nurse report immediately to the provider?

The patient who is having white milky liquid stools immediately after a barium enema.

The patient with irritable bowel syndrome (IBS) who has not had a bowel movement for three days.

The patient diagnosed with ulcerative colitis with a temperature of 101°F and abdominal distention.

The patient receiving Total Parenteral Nutrition (TPN) whose blood glucose level is 225 mg/dL.

Answer and Explanation

The Correct Answer is C

Choice A reason: White milky liquid stools immediately after a barium enema are not uncommon and are typically due to the passage of barium. This finding does not usually require immediate reporting unless there are other concerning symptoms.

Choice B reason: Not having a bowel movement for three days in a patient with irritable bowel syndrome (IBS) can be uncomfortable but is not typically an emergency. Management can be addressed through dietary and medication adjustments rather than immediate reporting.

Choice C reason: A temperature of 101°F and abdominal distention in a patient diagnosed with ulcerative colitis is concerning and should be reported immediately. These symptoms can indicate a serious complication such as toxic megacolon, perforation, or severe infection, which require prompt medical intervention.

Choice D reason: A blood glucose level of 225 mg/dL in a patient receiving Total Parenteral Nutrition (TPN) is elevated but not necessarily an emergency. Elevated blood glucose levels are a common side effect of TPN and can be managed through adjustments in insulin or TPN composition.

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Correct Answer is C

Explanation

Choice A reason: Large, bulky stools are not uncommon after a barium enema, as the barium can cause temporary changes in stool consistency and volume. This finding would not necessarily warrant immediate reporting to the healthcare provider unless there are other concerning symptoms.

Choice B reason: Three formed stools in eight hours may indicate increased bowel activity but is not an unusual finding after a barium enema. This would not typically be a cause for concern unless accompanied by other symptoms.

Choice C reason: Streaks of blood present in the stool is a concerning finding that should be reported to the healthcare provider. The presence of blood may indicate mucosal injury, inflammation, or other complications that need to be addressed promptly.

A. Advise the patient to consume protein and carbohydrates immediately. B. Notify the provider of the result and recommend that the patient's insulin dose be increased. C. Instruct the patient to withhold the next scheduled dose of insulin. D. Suggest that the patient asks their provider to start them on metformin therapy.

Correct Answer is B

Explanation

Choice A reason: Advising the patient to consume protein and carbohydrates immediately is not appropriate in this context. The presence of ketones in the urine indicates that the body is using fat for energy due to a lack of insulin. Increasing carbohydrate intake without addressing the underlying insulin deficiency can worsen hyperglycemia and ketoacidosis.

Choice B reason: Notifying the provider of the result and recommending that the patient's insulin dose be increased is the appropriate intervention. The presence of ketones in the urine indicates inadequate insulin levels, and adjusting the insulin dose can help correct the metabolic imbalance and prevent further complications such as diabetic ketoacidosis.

Choice C reason: Instructing the patient to withhold the next scheduled dose of insulin is incorrect. Insulin is essential for managing blood glucose levels and preventing ketosis in patients with type 1 diabetes. Withholding insulin can lead to severe hyperglycemia and ketoacidosis.

Choice D reason: Suggesting that the patient ask their provider to start them on metformin therapy is not appropriate for type 1 diabetes. Metformin is used primarily for type 2 diabetes and is not effective in type 1 diabetes, where insulin is required for glucose management.

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The nurse is in the G unit is assessing a patient after receiving the change of shift SBAR report. What assessment findings will the nurse report immediately to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient after a barium enema. When assessing the patient's subsequent bowel patterns and stools, what finding will the nurse report to the health care provider?

Correct Answer is C

Explanation

The nurse is admitting a patient with type 1 diabetes. While reviewing the patient's laboratory results, the nurse notes the presence of ketones in the urine. What intervention will the nurse implement for this patient?

Correct Answer is B

Explanation

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