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 O 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
A. The client reports a pain level of 6 on a scale from 0 to 10: Moderate pain is expected after surgery and should be managed, but it is not immediately life-threatening or the highest priority.
B. The client refuses to look at the colostomy: Emotional adjustment is important, but this does not pose an immediate physical risk to the client and can be addressed over time with support and education.
C. The colostomy has had no output: It is common for a new colostomy to have delayed output within the first 24 hours postoperatively, so this finding is expected and not immediately concerning.
D. The stoma appears dark purple in color: A dark purple stoma indicates compromised blood flow or ischemia, which is a medical emergency requiring immediate intervention to prevent tissue necrosis and further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. The client slept 5 hr the previous night: Acute manic episodes often involve severe sleep deprivation, sometimes going days without sleep. Achieving 5 hours of rest indicates reduced hyperactivity and a positive response to treatment.
B. The client takes 2 short naps during the day: While napping may seem beneficial, in manic clients it can indicate ongoing disrupted sleep-wake cycles. Full, restorative nighttime sleep is a more reliable sign of improvement.
C. The client consumes 8 oz of high-calorie fluids each hour: During mania, clients often neglect nutritional needs. Actively consuming adequate fluids suggests improved awareness, cooperation, and decreased impulsivity.
D. The client engages in quiet activities in their room: Initially, the client was extremely restless and disruptive. Choosing calm, solitary activities reflects improved impulse control and reduced manic energy.
E. The client appears to listen to unseen others: This suggests persistent auditory hallucinations, indicating that psychotic symptoms remain present and untreated or only partially managed. This is not a sign of improvement.
Correct Answer is ["A","D","E"]
Explanation
A. Check gastric residuals every 4 hr: Monitoring gastric residual volume every 4 hours helps assess tolerance to the feeding and prevents aspiration or overfeeding.
B. Ensure the formula is cold before administration: Cold formula can cause gastric cramping and discomfort. It should be at room temperature prior to administration.
C. Check placement of the feeding tube x-ray once daily: X-ray confirmation is typically done once upon initial insertion. Daily checks are not required unless there’s a concern about displacement.
D. Change the feeding container and tubing every 24 hr: This reduces the risk of bacterial contamination, especially since enteral nutrition provides a medium for microbial growth.
E. Maintain the head of the client’s bed at a 30° angle or higher: Elevating the head of the bed helps prevent aspiration by keeping gastric contents from refluxing into the esophagus.
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