Try Naxlex NCLEX-RN (Free-Trial)

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Complete the bath even if the client is in distress. – Forcing the bath can increase agitation and damage trust. If the client becomes distressed, pause, reassure, and try again later.

B. Allow the client to select the temperature of the bath water. – Clients with dementia may have impaired sensory perception, increasing the risk of burns or discomfort. The nurse should check the water temperature to ensure safety.

C. Give detailed instructions for the client to follow. – Clients with dementia may struggle to process multiple steps, leading to frustration. Instead, use simple, one-step instructions and gentle guidance.

D. Use distractions when bathing the client.Clients with dementia may experience anxiety, agitation, or distress during bathing. Using distractions, such as playing soothing music, talking about familiar topics, or providing a comforting touch, can help make the experience less stressful and more cooperative.

A. A client who requires teaching prior to discharge. B. A client who is watching a video about the meal services at the facility in their primary language. C. A client who is learning to use an incentive spirometer and has an interpreter present. D. A client who requires administration of a prescribed pain medication.

Correct Answer is A

Explanation

The nurse should provide written materials in the client's primary language for a client who requires teaching prior to discharge. This ensures that the client has access to important information in a language they understand and can refer to after leaving the facility.

b. A client who is watching a video about meal services in their primary language may not require additional written materials.

c. A client who is learning to use an incentive spirometer with the help of an interpreter may not require additional written materials.

d. The administration of a prescribed pain medication does not necessarily require the provision of written materials.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to bathe a client who has dementia. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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?

Correct Answer is A

Explanation

A nurse is planning care for a client who has a prescription for extremity restraints on both wrists. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

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 hospice nurse is visiting a client who has terminal cancer. Which of the following statements by the client's partner should the nurse recognize as an indication of anticipatory grief?

A nurse on a medical-surgical unit is caring for a client who reports difficulty sleeping at night. Which of the following findings should indicate to the nurse that the client has sleep deprivation?

A nurse hangs a bag of dextrose 5% in water, 1,000 mL at 0800 to run at 125 mL/hr. At 1200, the nurse notices that the client's IV bag is empty. Which of the following interventions should the nurse take first?

A nurse is preparing to palpate a client's systolic blood pressure using the brachial artery. After applying the blood pressure cuﬀ to the client's arm, identify the sequence of steps the nurse should follow. (Arrange the steps, placing them in the order of performance. Use all the steps.)

A nurse is caring for a client who is immunocompromised. Which of the following actions should the nurse take?