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 ["2"]
Explanation
- Convert the available strength from milligrams (mg) to micrograms (mcg) to match the desired dose's unit.
Available strength = 0.025 mg/tablet
Since 1 mg = 1000 mcg,
Calculation:
Desired dose = 50 mcg.
Available strength in mcg = 0.025 mg/tablet × 1000 mcg/mg
= 25 mcg/tablet.
Calculate the number of tablets to administer.
Number of tablets = Desired dose (mcg) / Available strength (mcg/tablet)
= 50 mcg / 25 mcg/tablet
= 2 tablets.
Correct Answer is A
Explanation
Rationale:
A. Action: The action stage involves actively implementing strategies to change behavior. Since the group is already in the process of reducing pesticide use, they are taking concrete steps toward achieving their goal, which defines the action phase.
B. Maintenance: Maintenance occurs after a behavior has been successfully adopted and sustained over time. The group has not yet reached this phase, as they are still actively working on the change rather than maintaining it.
C. Contemplation: Contemplation is the stage where individuals or groups are considering a change but have not yet committed to or started the process. The group’s involvement in reducing pesticide use suggests they have moved beyond this phase.
D. Preparation: Preparation includes making plans and gathering resources to initiate change. While the group may have gone through this stage, the current activity of reducing pesticide use indicates they have progressed to the action stage.
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