You are providing care for a patient who had an ileostomy placed one week ago after a bowel resection. You note the following findings during your assessment (see chart below):

Stoma Assessment

Stoma is protruding 2cm, is red and moist. Peristomal area is clean and intact.

Output

Liquid stool that is malodorous. Gas present in the appliance.

General Status

Patient is avoiding looking at the ileostomy during care.

Laboratory Data

Potassium 3.6 mEq/L (normal 3.5 to 5 mEq/L)

Sodium 137 mEq/L (normal 135 to 145 mEq/L)

Creatinine 0.9 mg/dL (normal 0.6 to 1.2 mg/dL)

What finding is most concerning to the nurse?

Output assessment

General Status

Stoma assessment

Laboratory data

Answer and Explanation

The Correct Answer is B

A. Output assessment: Liquid stool and gas output are expected findings for an ileostomy.

B. General status: The patient’s avoidance of looking at the ileostomy suggests poor adaptation and possible psychological distress, which may require intervention.

C. Stoma assessment: A red, moist, and protruding stoma is a normal finding.

D. Laboratory data: The patient’s potassium level is on the lower end but still within normal limits. There are no critical abnormalities.

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Correct Answer is D

Explanation

A. Elbows and behind the ears: These areas are not primary pressure points in a seated position.

B. Coccyx and back of the skull: The coccyx is a pressure point when lying down, but this patient is sitting most of the time.

C. Heels and trochanter: Heels are at risk in supine patients, but this patient is primarily sitting.

D. Sacrum and ischium: The sacrum and ischium (sit bones) bear the most pressure in a seated position, making them highly vulnerable to skin breakdown.

A. "Patient with complaints of urinary incontinence." B. "Patient reports urinary retention." C. "Patient reports urinary frequency." D. "Patient has an enlarged prostate."

Correct Answer is B

Explanation

A. "Patient with complaints of urinary incontinence." The patient did not report involuntary leakage of urine, which defines incontinence.
B. "Patient reports urinary retention." Urinary retention refers to the inability to completely empty the bladder, which matches the patient's description.
C. "Patient reports urinary frequency." Urinary frequency means voiding frequently (e.g., every 1-2 hours), but the patient described difficulty emptying.
D. "Patient has an enlarged prostate." While an enlarged prostate (BPH) could cause retention, the nurse should not diagnose—only report symptoms.

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Laboratory Test	Reference Range	Patient Results
White Blood Cells	5,000- 10,000/mm3	9,500/mm3
Neutrophil Count	2.500-8,000/mm3	5,200/mm3
HIV	Negative	Positive

Stoma Assessment	Stoma is protruding 2cm, is red and moist. Peristomal area is clean and intact.
Output	Liquid stool that is malodorous. Gas present in the appliance.
General Status	Patient is avoiding looking at the ileostomy during care.
Laboratory Data	Potassium 3.6 mEq/L (normal 3.5 to 5 mEq/L) Sodium 137 mEq/L (normal 135 to 145 mEq/L) Creatinine 0.9 mg/dL (normal 0.6 to 1.2 mg/dL)

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Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult patient with chronic obstructive pulmonary disease. The patient always remains in a sitting position to help them breathe more easily. Based on this information, what area on the patient's body should be frequently assessed for skin breakdown?

Correct Answer is D

Explanation

During a health history interview, a client tells the nurse that they do not feel that they completely empty the bladder when they void. How would the nurse report this findings to the provider?

Correct Answer is B

Explanation

A patient has called the nurse to help them ambulate to the bathroom. The nurse assists the patient to a dangling position on the bed and applied the gait belt. Upon standing, the patient reports that they are feeling very dizzy. What is the next best action by the nurse?

Which of the following patients are at highest risk for developing a skin injury caused by shearing?

A student nurse is assessing their patient who is NPO due to a recent surgery. The provider comes in the room to see the patient and states that the patient is cleared to start a full liquid diet. What is the best action by the student nurse?

A client has developed edema in her lower legs and feet prompting her physician to prescribe furosemide, a diuretic medication. After the client has begun this new medication, what should the nurse anticipate as a normal finding?

A student nurse is assigned a patient to provide care for throughout the day. Which of the following actions would violate client confidentiality?

The nurse has received a report for the following patients. Which patient should be seen first?