The nurse is emptying an ileostomy pouch for a patient. Which assessment finding would the nurse report immediately?
Liquid consistency of stool
Unpleasant odor from the stool
Presence of blood in the stool
Continuous output from the stoma
The Correct Answer is C
Choice A For an ileostomy, liquid consistency of stool is expected as the output, and it is not an immediate concern.
Choice B Foul odor from the stool is common with ileostomy output, and while it can be unpleasant, it is not an immediate concern.
Choice C This finding should be reported immediately, as it could indicate bleeding from the stoma or intestinal mucosa, which requires prompt evaluation and intervention.
Choice D Continuous output from an ileostomy is normal and expected, so it is not a cause for immediate concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A The supine position is not suitable for administering an enema as it does not facilitate proper flow and retention of the solution.
Choice B High Fowler's position is not the best option for enema administration, as it might cause discomfort and hinder proper administration.
Choice C Semi Fowler's position is also not the best option for enema administration, as it may not allow the solution to flow effectively.
Choice D The Sims position, with the patient lying on the left side with the right knee flexed, allows the enema solution to flow downward by gravity and improves retention. It is the best position for enema administration.
Correct Answer is A
No explanation
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