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 A

Explanation

Rationale:

A. Eat a light snack before bedtime: A light snack can prevent hunger from interfering with sleep and promote relaxation. Complex carbohydrates or small amounts of protein may help induce sleep without causing gastrointestinal discomfort.

B. Perform exercises prior to bedtime: Vigorous physical activity before bed can stimulate the body and make it harder to fall asleep. Exercise is beneficial when done earlier in the day, ideally several hours before bedtime.

C. Stay in bed at least 1 hr if unable to fall asleep: Staying in bed while unable to sleep can create negative associations with the bed and worsen insomnia. It's more effective to get up, engage in a quiet activity, and return to bed once sleepy.

D. Take a 1-hr nap during the day: Long daytime naps can reduce sleep pressure at night and interfere with falling or staying asleep. If needed, naps should be limited to 20–30 minutes and taken early in the day.

A. Canned black beans B. Cheese C. Fish D. Red meat

Correct Answer is C

Explanation

Rationale:

A. Canned black beans: While black beans are nutritious, the canned variety often contains high sodium content, which can contribute to elevated blood pressure. Unless rinsed or labeled low-sodium, they are not ideal for a hypertension diet.

B. Cheese: Many cheeses are high in sodium and saturated fats, which can worsen hypertension. Regular consumption should be limited or replaced with low-sodium, low-fat alternatives.

C. Fish: Fish, especially fatty varieties like salmon and mackerel, are rich in omega-3 fatty acids, which support cardiovascular health and help lower blood pressure. They are a heart-healthy protein choice for individuals with hypertension.

D. Red meat: Red meat is often high in saturated fat and sodium, particularly when processed. Frequent intake is associated with increased blood pressure and cardiovascular risks, making it less suitable for a hypertension-friendly diet.

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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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