You are providing care for a patient who had an ileostomy placed one week ago after a bowel resection. You note the following findings during your assessment (see chart below):

Stoma Assessment

Stoma is protruding 2cm, is red and moist. Peristomal area is clean and intact.

Output

Liquid stool that is malodorous. Gas present in the appliance.

General Status

Patient is avoiding looking at the ileostomy during care.

Laboratory Data

Potassium 3.6 mEq/L (normal 3.5 to 5 mEq/L)

Sodium 137 mEq/L (normal 135 to 145 mEq/L)

Creatinine 0.9 mg/dL (normal 0.6 to 1.2 mg/dL)

What finding is most concerning to the nurse?

Output assessment

General Status

Stoma assessment

Laboratory data

Answer and Explanation

The Correct Answer is B

A. Output assessment: Liquid stool and gas output are expected findings for an ileostomy.

B. General status: The patient’s avoidance of looking at the ileostomy suggests poor adaptation and possible psychological distress, which may require intervention.

C. Stoma assessment: A red, moist, and protruding stoma is a normal finding.

D. Laboratory data: The patient’s potassium level is on the lower end but still within normal limits. There are no critical abnormalities.

Nursing Test Bank

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Correct Answer is C

Explanation

A. Ensure the patient is safe and leave to get them some water: The provider’s verbal statement is not an official order. The student nurse must ensure a written order is in place before implementing dietary changes.

B. Contact dietary to order the patient a full liquid meal: The student nurse cannot place orders. They must first verify that the provider has documented the order.

C. Request that the provider write the order in the chart: Orders must be documented in the patient’s medical record before they can be carried out. The student nurse should ensure the provider formally writes the order.

D. Record the information in the patient chart: The student nurse cannot chart an order that has not been officially written by the provider.

A. 4 B. 1 C. 2 D. 8

Correct Answer is D

Explanation

Determine the dose per administration:

1000 mg ÷ 250 mg/capsule = 4 capsules per dose

Calculate the total per day:

Since the order is every 12 hours, the medication is given twice a day
4 capsules per dose × 2 doses per day = 8 capsules per day

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Stoma Assessment	Stoma is protruding 2cm, is red and moist. Peristomal area is clean and intact.
Output	Liquid stool that is malodorous. Gas present in the appliance.
General Status	Patient is avoiding looking at the ileostomy during care.
Laboratory Data	Potassium 3.6 mEq/L (normal 3.5 to 5 mEq/L) Sodium 137 mEq/L (normal 135 to 145 mEq/L) Creatinine 0.9 mg/dL (normal 0.6 to 1.2 mg/dL)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A student nurse is assessing their patient who is NPO due to a recent surgery. The provider comes in the room to see the patient and states that the patient is cleared to start a full liquid diet. What is the best action by the student nurse?

Correct Answer is C

Explanation

Order: Ampicillin 1000 mg PO every 12 hours Available: Ampicillin 250 mg capsules How many capsules will you administer per day?

Correct Answer is D

Explanation

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