A nurse is assessing a client who had a colostomy 24 hr ago. Which of the following findings is the nurse's priority?

The client reports a pain level of 6 on a scale from 0 to 10

The client refuses to look at the colostomy

The colostomy has had no output

The stoma appears dark purple in color

Answer and Explanation

The Correct Answer is D

Rationale:

A. The client reports a pain level of 6 on a scale from 0 to 10: Moderate pain is expected postoperatively and should be managed, but it does not indicate an immediate threat to tissue viability or life. It is not the top priority when compared to signs of stoma compromise.

B. The client refuses to look at the colostomy: Emotional adjustment is important and should be addressed with sensitivity, but it is a psychosocial concern rather than a physiological emergency. This can be prioritized after physical complications are ruled out.

C. The colostomy has had no output: Absence of output within the first 24 hours may be related to bowel manipulation during surgery. While it should be monitored, it is not as urgent as signs suggesting stoma necrosis or ischemia.

D. The stoma appears dark purple in color: A dark purple stoma indicates poor perfusion or possible necrosis, which is a surgical emergency. A healthy stoma should appear pink or red and moist. Immediate intervention is required to preserve tissue viability.

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Correct Answer is D

Explanation

Rationale:

A. Insert the oral thermometer in front of the infant's tongue: Oral temperature measurement is not appropriate for infants due to the risk of injury and their inability to hold the thermometer properly. It is generally reserved for children older than 4–5 years.

B. Pull the pinna of the infant's ear forward before inserting the probe: When using a tympanic thermometer for infants under 3 years, the correct method is to pull the pinna down and back, not forward, to straighten the ear canal.

C. Insert the probe 3.8 cm (1.5 in) into the infant's rectum: This depth is too invasive and risks rectal perforation. For infants, rectal insertion should be only 1.5 to 2.5 cm (0.6–1 in), with extreme caution.

D. Place the tip of the thermometer under the center of the infant's axilla: Axillary temperature is the safest and most noninvasive route for infants. Ensuring full skin contact under the center of the axilla provides the most accurate axillary reading.

A. Insert an indwelling urinary catheter. B. Administer packed RBCs. C. Obtain a specimen for ABG analysis. D. Place a large-bore IV catheter in an upper extremity.

Correct Answer is D

Explanation

Rationale:

A. Insert an indwelling urinary catheter: While important for monitoring urine output and renal perfusion, catheter insertion is not the immediate priority in a trauma situation. It should be done after vascular access is secured and life-threatening conditions are addressed.

B. Administer packed RBCs: Blood transfusion is critical for managing hemorrhagic shock, but it cannot be initiated until a large-bore IV is placed. Vascular access is necessary before any fluid or blood product administration.

C. Obtain a specimen for ABG analysis: ABGs provide valuable data on oxygenation and acid-base balance but are diagnostic rather than life-sustaining. This step is less urgent than establishing IV access for fluid resuscitation or transfusion.

D. Place a large-bore IV catheter in an upper extremity: In trauma care, rapid IV access is the top priority to allow fluid and blood product resuscitation. A large-bore catheter ensures high-volume administration, which is essential in potential hemorrhagic shock.

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A nurse is assessing a client who had a colostomy 24 hr ago. Which of the following findings is the nurse's priority?

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