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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A,B,C,D
Explanation
Rationale:
A. Rolls from back to side: This is typically the first gross motor milestone among the listed options and usually occurs around 4 months of age. It marks early trunk and upper body control development.
B. Rolls from back to abdomen: Rolling from back to abdomen requires more strength and coordination and generally occurs around 5 to 6 months of age, following the ability to roll to the side.
C. Sits steadily unsupported: Infants begin sitting without support around 7 to 8 months, once they develop adequate trunk and head control. This milestone represents a major progression in balance and posture.
D. Changes from prone to sitting: Transitioning from a prone to a sitting position typically develops around 9 to 10 months. It involves coordinated control of the arms, trunk, and legs and reflects advanced gross motor skill development.
Correct Answer is B
Explanation
Rationale:
A. "Surprise your son with a new bedroom after you bring the baby home.": Sudden changes, especially without preparation, can increase feelings of insecurity or jealousy in young children. Involving the child in changes before the baby arrives helps promote acceptance and reduces anxiety.
B. "Purchase a gift to give to your son from your baby.": This strategy helps foster a positive bond between the older sibling and the newborn. It helps the child feel acknowledged and valued during a time when attention naturally shifts to the new baby.
C. "Make sure you are holding your baby when your son comes to visit you in the hospital.": Holding the baby during the first meeting can intensify feelings of displacement or jealousy in the older child. It's better to greet the child warmly and introduce the baby together to maintain emotional connection.
D. "Use medical terminology when teaching your son about your new baby.": Preschool-aged children benefit more from simple, age-appropriate explanations. Medical jargon can confuse or overwhelm them, making it harder to process the concept of a new sibling.
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