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 B
No explanation
Correct Answer is A
Explanation
A. When the left descending colon and rectum are removed, a colostomy is typically created. This involves bringing the proximal end of the remaining colon to the surface of the abdomen to create a stoma. The colostomy allows the rest of the bowel to heal and function normally.
B.A continent ostomy involves creating an internal reservoir with a valve, allowing the patient to control the evacuation of intestinal contents. This option is less common and usually associated with continent ileostomies rather than temporary diversions to rest a portion of the colon.
C. A Kock pouch is a type of continent ileostomy where an internal reservoir is created from the ileum, and the patient can empty the reservoir with a catheter. This is not typically used as a diversion for healing purposes involving the colon.
D.An ileostomy involves bringing the end of the ileum (the last part of the small intestine) to the surface of the abdomen to create a stoma. Given that the left descending colon and rectum were removed, this procedure is unlikely unless the entire colon is bypassed or removed, which is not specified in this scenario.
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