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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Determine if the stockings are binding. It is important to assess that antiembolic stockings are not too tight, especially around the top, as this can impair circulation. Proper fit ensures they function effectively to promote venous return and prevent deep vein thrombosis.
B. Fold the top of the stocking over neatly. Folding or rolling the tops can cause constriction and act like a tourniquet, reducing circulation and increasing the risk of complications such as venous stasis or skin breakdown.
C. Apply the stockings after the client is in a chair. Antiembolic stockings should be applied while the client is lying down, before getting up, to prevent blood pooling in the legs. Applying them after the client is upright may reduce their effectiveness.
D. Massage the client's legs once every 8 hr while the stockings are in place. Massaging the legs, especially in clients at risk for thrombosis, is not recommended as it could dislodge a clot and lead to embolism. Passive or active leg movement is safer and more effective.
Correct Answer is A
Explanation
A. Lorazepam. Lorazepam is a benzodiazepine and the first-line medication for treating status epilepticus due to its rapid onset of action. It acts by enhancing the effect of GABA, an inhibitory neurotransmitter, helping to quickly stop continuous seizure activity.
B. Carbamazepine. Carbamazepine is used for long-term seizure control, particularly in partial seizures, but it is not appropriate for emergency treatment of status epilepticus due to its slower onset of action and oral route of administration.
C. Lamotrigine. Lamotrigine is also used for chronic seizure management, including generalized and partial seizures. However, it is not effective in acute seizure emergencies and is typically not administered intravenously.
D. Clonazepam. While clonazepam is a benzodiazepine used to manage seizures, it is generally used for maintenance therapy. It lacks the fast-acting IV formulation preferred in treating status epilepticus, unlike lorazepam.
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