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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?

A.

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

B.

The client refuses to look at the colostomy

C.

The colostomy has had no output

D.

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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Related Questions

Correct Answer is C

Explanation

Rationale:

A. Emphasize vowel sounds when speaking: Vowel sounds are not as difficult to hear as consonants, especially for clients with sensorineural hearing loss. Overemphasizing vowel sounds can distort speech and make understanding more difficult.

B. Lower the tone of voice at the end of each sentence: Lowering the tone may cause parts of the message to be missed, especially if the client relies on lip-reading or residual hearing. A consistent tone and clear enunciation are more effective communication strategies.

C. Decrease background noise when talking with the client: Reducing background noise improves the client’s ability to focus on the speaker and hear more clearly. Background noise can interfere with hearing aids and make communication more challenging for individuals with hearing impairment.

D. Sit next to the client when speaking to them: Sitting next to the client may reduce their ability to see facial expressions or lip-read. It is more effective to sit directly in front of them and maintain eye contact to facilitate clear communication.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A","dropdown-group-3":"A"}

Explanation

Rationale for correct choices:

  • Preeclampsia: The client presents with classic signs of preeclampsia, including elevated blood pressure (156/96 mm Hg), facial and dependent edema, hyperreflexia (DTR 3+), and right upper quadrant pain. Laboratory findings such as thrombocytopenia, elevated liver enzymes, and proteinuria also support this diagnosis.
  • Urinalysis: Proteinuria is a key diagnostic criterion for preeclampsia, and this client’s urinalysis reveals protein levels (25 mg/dL) above normal limits, indicating kidney involvement and supporting the preeclampsia diagnosis.
  • Pain assessment: Right upper quadrant pain is a significant symptom of preeclampsia, suggesting hepatic involvement such as liver capsule distension or possible HELLP syndrome. This pain, combined with other clinical and lab findings, signals severity and risk for maternal complications.

Rationale for incorrect choices:

  • Chorioamnionitis: This infection is typically accompanied by fever, uterine tenderness, and foul-smelling discharge. The client is afebrile with clear lungs and no uterine tenderness, making chorioamnionitis unlikely.
  • Preterm labor: No contractions or cervical changes were noted. The fetal heart rate is normal, and the client’s symptoms do not suggest imminent labor.
  • Serum WBC count: The client’s WBC count is within normal limits, which does not support infection or inflammatory processes related to chorioamnionitis.
  • Fundal assessment: Fundal height of 29 cm at 30 weeks is appropriate and shows no evidence of uterine enlargement or contraction indicative of preterm labor.
  • Fetal monitor results: The fetal heart rate is 140/min and stable, showing no signs of distress that would suggest preterm labor or infection.
  • Hemoglobin: Hemoglobin is within normal limits and does not contribute to the risk assessment for preeclampsia or infection.

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