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 A
Explanation
The nurse should respect the client's autonomy and right to make decisions about their own care. Referring the client to hospice care is an appropriate response because it provides the client with support and care in their own home.
Options b, c, and d are not appropriate responses because they do not respect the client's autonomy.
Option b suggests that the client needs to discuss their decision with their family before making a decision, which may not be necessary or desired by the client.
Option c confronts the client with the reality of their illness in a potentially insensitive manner.
Option d suggests that the client is giving up too soon, which may not be an accurate or helpful assessment of the situation.
Correct Answer is B
Explanation
The correct answer is that the nurse should include information about the effectiveness of the last dose of pain medication in the hand-off report when transferring a client to a long-term care facility. This information is important for the receiving facility to continue managing the client's pain effectively.
Options a, c and d are not essential information to include in the hand-off report. The time of the client's last bath, the number of family members who have visited and the frequency of previous vital sign measurement are not critical for ensuring continuity of care during the transfer.
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