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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

The correct answer is that discussing the client's transfer to a long-term care facility with a nurse from another unit is a violation of HIPA

A. HIPAA regulations require that healthcare providers protect the privacy of their clients' personal health information (PHI) and only share it with authorized individuals on a need- to-know basis.

Options a, b and d are not violations of HIPAA. Faxing medical information to the client's provider's office, teaching the client discharge instructions with his partner present and giving a telephone report to a surgical nurse when sending the client to the surgical suite are all acceptable practices under HIPAA regulations.

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.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

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 teaching a client who requires maximal support about how to use a two-wheeled walker. Which of the following actions by the client indicates an understanding of teaching?

A nurse in an acute care facility is preparing to transfer a client to a long-term care facility. Which of the following information should the nurse include in the hand-oﬀ report?

A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?

A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?

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

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?