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

Answer and Explanation

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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Correct Answer is A

Explanation

A. Place the tip of the thermometer under the center of the infant's axilla: This is the correct method for taking an axillary temperature in infants, which is the recommended route due to safety and ease. The tip should be placed snugly in the center of the axilla and the infant's arm should be held firmly against their body to ensure accuracy.
B. Pull the pinna of the infant's ear forward before inserting the probe: This technique is used for otoscopic or tympanic temperature readings in children under 3, but tympanic readings are not preferred in young infants due to the small size and curvature of their ear canals, which can lead to inaccuracy.
C. Insert the oral thermometer in front of the infant's tongue: Oral temperature measurement is inappropriate for infants. They may not be able to keep the thermometer properly positioned, which increases the risk of inaccurate readings or injury.
D. Insert the probe 3.8 cm (1.5 in) into the infant's rectum: Rectal temperature measurement is not routinely recommended unless specifically indicated, and the probe should only be inserted about 1.3 cm (0.5 in) for infants to avoid rectal perforation. The option listed suggests unsafe depth.

A. Complete activities for one client before moving to the next client. B. Document assessment findings and interventions after providing care for a group of clients. C. Gather supplies for a client's dressing change after removing the old dressing. D. Delay cleaning personal work area until the end of the shift.

Correct Answer is A

Explanation

A. Complete activities for one client before moving to the next client. Focusing on completing tasks for one client at a time helps ensure safe, uninterrupted care, reduces errors, and promotes efficiency in task completion.
B. Document assessment findings and interventions after providing care for a group of clients. Delaying documentation increases the risk of forgetting important details and may lead to inaccuracies. Documentation should be done promptly after care is provided.
C. Gather supplies for a client's dressing change after removing the old dressing. Supplies should be gathered before beginning a procedure to prevent delays, reduce exposure time, and avoid leaving the client unattended.
D. Delay cleaning personal work area until the end of the shift. Maintaining a clean and organized workspace throughout the shift improves efficiency, infection control, and safety, especially in shared environments.

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A nurse is assessing a client who had a colostomy 24 hrs ago. Which of the following findings is the nurse's priority?

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