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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

Answer and Explanation

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.

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Correct Answer is D

Explanation

When caring for a client who has a chest tube following thoracic surgery, the nurse can delegate the task of assisting the client to select food choices from the menu to an assistive personnel. This task is within the scope of practice of an assistive personnel and does not require the specialized knowledge or judgment of a nurse.

Option a is incorrect because monitoring the characteristics of the client's chest tube drainage requires specialized knowledge and should not be delegated.

Option b is incorrect because evaluating the client's response to pain medication requires specialized knowledge and should not be delegated.

Option c is incorrect because teaching deep breathing and coughing to the client requires specialized knowledge and should not be delegated.

A. Age B. Room number C. Photograph D. Bed number

Correct Answer is C

Explanation

A.Age alone is not a reliable or unique identifier. Many clients can share the same age, and this information does not sufficiently confirm an individual’s identity. Using age alone could lead to errors, as it lacks specificity.

B.Room numbers are not reliable for client identification because clients may be moved to different rooms or share rooms with others. Using a room number alone could easily lead to a medication error, as it does not confirm the client’s personal identity.

C.Using a photograph is an acceptable form of client identification, especially in settings where clients may not be able to verbally confirm their identity (e.g., clients with dementia). Photographs, when available, are typically included in the client’s medical records and can help ensure correct patient identification to prevent medication errors.

D.Bed numbers, similar to room numbers, are not unique to an individual and may change or be shared in multi-bed rooms. Relying on a bed number could result in giving medication to the wrong client, which is a significant risk to client safety.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a chest tube following thoracic surgery. Which of the following tasks should the nurse delegate to an assistive personnel?

Correct Answer is D

Explanation

A nurse is preparing to administer a medication to a client. Which of the following should the nurse use as a client identifier?

Correct Answer is C

Explanation

A nurse is caring for an older adult client who tells the nurse, "I have smoked one pack of cigarettes every day for the last 60 years." Which of the following actions should the nurse take next?

A nurse is caring for a group of clients whose primary languages are diﬀerent from the nurse's. For which of the following clients should the nurse provide written materials in the client's primary language?

A nurse is caring for a client who has a new diagnosis of a terminal illness. The client states, "I do not want any treatment. I would like to go home." Which of the following responses should the nurse make?

A nurse is caring for a client who is agitated and threatening to harm others. The nurse places the client in restraints but does not notify the provider or obtain a prescription for the restraints. This situation represents which of the following torts?

A visitor reports to a nurse that she slipped and fell in a client's room. The visitor denies any injury, but is walking with a slight limp. Which of the following actions should the nurse take?

A nurse is reviewing client confidentiality with a newly licensed nurse. The nurse should identify which of the following examples as a violation of HIPAA?

A nurse is preparing to insert a peripheral IV catheter into a client's arm. Which of the following actions should the nurse take to help dilate the vein?

A nurse is caring for a client who has chronic back pain and asks about receiving acupuncture for relief. Which of the following findings should the nurse identify as a contraindication to receiving this treatment?