A nurse is caring for a client who has an ileostomy.
Nurses' Notes
Day 1:
- Client is alert and oriented.
- ileostomy stoma is pink.
- Stoma draining moderate brown liquid stool.
- Client will not look at the stoma.
- Client states they are not interested in learning about stoma care.
- Intake: 2,200 mL over the last 24 hr
- Urine output: 1,200 ml over the last 24 hr
Day 2:
- ileostomy pouch changed. Skin surrounding the stoma is reddened and appears irritated
- initiated a request for a referral to an ostomy nurse.
- intake. 1,600 mL over the last 24 hr
- Urine output: 650 mL over the last 24 hr
The nurse is reviewing the client's medical record. Select the information that requires intervention by the nurse.
Ileostomy stoma is pink.
Stoma draining moderate brown liquid stool.
Client will not look at the stoma.
Client states they are not interested in learning about stoma care
Intake: 2,200 mL over the last 24 hr
Skin surrounding the stoma is reddened and appears iritated
Urine output: 650 mL over the last 24 hr
Correct Answer : F
f) Skin surrounding the stoma is reddened and appears irritated.
The information that requires intervention by the nurse is that the skin surrounding the stoma is reddened and appears irritated. This may indicate that the client is experiencing skin irritation or breakdown, which can lead to infection or other complications. The nurse should assess the skin and initiate appropriate interventions to prevent further skin damage.
Options a, b, c, d, e, and g do not necessarily require intervention by the nurse. A pink ileostomy stoma and moderate brown liquid stool drainage are normal findings. The client's refusal to look at the stoma or learn about stoma care may be concerning, but it is not an immediate priority for intervention. An intake of 2,200 mL over 24 hours and a urine output of 650 mL over 24 hours are within normal limits.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The Braden scale measures six elements: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Each element has a range of one to four points, with a total possible score of 23 points. The lower the score, the higher the risk for pressure injury.
Option a is incorrect because each element has a range from one to four points.
Option b is incorrect because the lower the score, the higher the pressure injury risk.
Option d is incorrect because the client's age is not part of the measurement.
Correct Answer is B
Explanation
When providing preoperative teaching to a client over the phone in preparation for outpatient surgery, the nurse should explain the need for the client to have another adult drive them home following surgery. This is because the client may still be affected by anesthesia and may not be able to safely operate a vehicle.
a. Asking the client to shower 3 times the day before surgery is not necessary and may dry out the skin.
c. The client should typically stop drinking clear liquids 2 hours before surgery, not 1 hour.
d. The client should not wear makeup during surgery as it can interfere with the monitoring of their skin color and oxygen saturation.
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