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.

Nursing Test Bank

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Correct Answer is D

Explanation

A. "Void every four hours even if you feel like you do not need to urinate." While frequent voiding is beneficial, forcing a rigid schedule is not necessary. The priority is voiding after intercourse and staying hydrated to flush bacteria.

B. "You should perform Kegel exercises several times a day." Kegel exercises strengthen the pelvic floor but do not prevent UTIs.

C. "When possible, you should try to take a tub bath instead of a shower." Soaking in a bath can introduce bacteria into the urethra, increasing UTI risk. Showers are recommended.

D. “It is important to clean front to back during bathing and after using the restroom.” Wiping front to back prevents the spread of bacteria from the perineal area to the urethra, a major cause of UTIs.

A. Inspect the patient's feet for a diabetic ulcer. B. Expose the full body to ensure efficiency. C. Encourage the patient to provide self-care. D. Apply baby powder to the perineal area and skin folds.

Correct Answer is C

Explanation

A. Inspect the patient's feet for a diabetic ulcer: Patients with obesity are at increased risk for skin breakdown, and foot ulcers may go unnoticed. Early detection prevents complications.

B. Expose the full body to ensure efficiency: Patients should be kept covered as much as possible to maintain dignity, privacy, and body temperature.

C. Encourage the patient to provide self-care: If the patient is able, self-care promotes independence and helps maintain mobility.

D. Apply baby powder to the perineal area and skin folds: Powder can clump and retain moisture, leading to skin irritation and fungal infections, especially in skin folds.

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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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