A nurse is assessing a client who had a colostomy 24 hrs ago. Which of the following findings is the nurse's priority?
The stoma appears dark purple in color.
The colostomy has had no output.
The client refuses to look at the colostomy.
The client reports a pain level of 6 on a scale from 0 to 10
The Correct Answer is A
A. The stoma appears dark purple in color. This is a priority finding, as it may indicate impaired circulation or necrosis of the stoma tissue. A healthy stoma should appear pink or red and moist. A dark purple or black color requires immediate evaluation.
B. The colostomy has had no output. While it is important to monitor output, it is not unusual for a new colostomy to have minimal or no output in the first 24–48 hours post-op as bowel function returns.
C. The client refuses to look at the colostomy. This is a psychosocial concern and may indicate body image issues or denial, but it is not the most urgent issue in the immediate postoperative period.
D. The client reports a pain level of 6 on a scale from 0 to 10. Pain management is important, but a pain level of 6, while needing intervention, does not take priority over a potential vascular compromise of the stoma.
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Related Questions
Correct Answer is C
Explanation
A. “Take your diuretic medication with your evening meal." Taking diuretics in the evening can increase nighttime urination, worsening sleep disruption and incontinence. They should generally be taken in the morning to minimize nocturia.
B. "Decrease your intake of cranberry juice." Cranberry juice is often recommended to promote urinary tract health, though it doesn’t directly worsen urge incontinence. It is not necessary to avoid it unless advised by a provider for another reason.
C. "Plan to urinate every 3 hours while you are awake." Scheduled voiding at regular intervals is a key strategy in bladder retraining. It helps reduce urgency episodes and gradually increases bladder capacity and control over time.
D. “Limit your fluid intake to 500 milliliters per day." Severely limiting fluids can lead to dehydration, concentrated urine, and bladder irritation, potentially worsening incontinence. Adequate fluid intake should be maintained unless otherwise directed.
Correct Answer is D
Explanation
A. "You should take a second dose if there is no relief within fifteen minutes after the initial dose." The second dose of sumatriptan should not be taken sooner than 2 hours after the first dose if there is no relief or if the migraine returns. Taking it too soon increases the risk of adverse effects.
B. "You may experience low blood pressure while taking this medication." Sumatriptan more commonly causes hypertension, not hypotension. It can cause vasoconstriction, which may elevate blood pressure and poses risks, especially in clients with cardiovascular disease.
C. "You should have complete relief in six hours after taking this medication." Relief from sumatriptan is often experienced within 1–2 hours after administration. While not all clients achieve complete relief, the medication acts quickly, and six hours is not the expected timeframe.
D. “You may experience muscle cramps as a potential adverse effect of the medication." Muscle cramps or tightness in the chest, neck, or limbs can occur due to vasoconstriction caused by sumatriptan. This is a known side effect and should be reported if severe or persistent.
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