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 B
Explanation
Rationale:
A. Use Leopold maneuvers to determine the fetal position: Leopold maneuvers are not appropriate as an immediate response to sudden nausea. The priority is to relieve the symptom, which may be related to positional compression of major blood vessels.
B. Position the client on her side: At 36 weeks gestation, the gravid uterus can compress the inferior vena cava when lying supine, leading to supine hypotensive syndrome. Symptoms like nausea, dizziness, and hypotension can occur. Side-lying positioning relieves the pressure and restores venous return and cardiac output.
C. Administer propranolol IV to the client: Propranolol is not indicated for treating pregnancy-related nausea or hypotension. Using it without a cardiovascular diagnosis would be inappropriate and could worsen hypotensive symptoms.
D. Ask the client to increase her daily calcium intake: While calcium is essential in pregnancy, especially for fetal bone development, increasing calcium intake has no immediate impact on sudden nausea or circulatory symptoms linked to maternal positioning.
Correct Answer is D
Explanation
Rationale:
A. Select a site on the client’s dominant arm: While either arm can be used, the nondominant arm is typically preferred to reduce interference with daily activities. Using the dominant arm may be more uncomfortable for the client post-insertion.
B. Elevate the client’s arm prior to insertion: Elevating the arm can reduce venous filling, making veins less visible and harder to access. Instead, the arm should be in a dependent position to encourage venous distension.
C. Apply a tourniquet below the venipuncture site: The tourniquet must be applied 10 to 15 cm (4 to 6 inches) above the intended insertion site to promote vein engorgement and visibility, not below it.
D. Choose a vein that is palpable and straight: A vein that is straight and palpable is ideal for IV insertion because it offers a predictable path and is less likely to be damaged during catheter advancement, reducing complications.
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