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 C
Explanation
A. “Use an indoor tanning bed instead of outside.”: Indoor tanning exposes the skin to concentrated ultraviolet radiation, which significantly increases the risk of developing skin cancer, including melanoma. It is not a safe alternative to outdoor sun exposure.
B. “Plan to spend time tanning between 10 am and 2 pm.”: This time frame represents peak UV radiation hours, and sun exposure should be minimized during this period to reduce the risk of skin damage and cancer.
C. “Apply sunscreen before and after swimming.”: Sunscreen should be applied 15–30 minutes before sun exposure and reapplied after swimming or sweating. Water can wash off sunblock, so reapplication helps maintain effective protection against UV rays.
D. “Use sunblock with an SPF of 10 when I am outdoors.”: An SPF of 10 provides minimal protection and is inadequate for preventing skin damage. A minimum SPF of 30 is recommended for effective protection against both UVA and UVB radiation.
Correct Answer is D
Explanation
A. Warm the irrigation solution: While warming may enhance comfort, it does not impact the color of urine or address post-procedure bleeding. It is not a necessary intervention in this situation.
B. Perform the Credé's maneuver: This technique, which involves manual pressure over the bladder, is used for clients with neurogenic bladder or urinary retention. It is not appropriate during continuous bladder irrigation.
C. Replace the indwelling urinary catheter: Catheter replacement would only be considered if there was a complete blockage that couldn't be cleared, severe kinking, or signs of infection, none of which are indicated here. Replacing the catheter unnecessarily increases the risk of trauma and infection.
D. Maintain the irrigation solution rate: Pink-tinged urine is expected within the first few hours following TURP as a result of minor bleeding. Continuing irrigation at the current rate helps prevent clot formation and maintains catheter patency.
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