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 D
Explanation
A. Revise the current policy for catheter care. Policy changes should be based on evidence and root cause analysis. Revising the policy prematurely without identifying contributing factors may not address the actual causes of infection.
B. Schedule nursing staff training for infection control procedures. Education and training are important but should be guided by identified gaps. Implementing training without understanding the root cause may result in ineffective interventions.
C. Meet with providers to discuss measures to decrease the infections. While interdisciplinary collaboration is valuable, it should occur after gathering and analyzing relevant data. This ensures targeted, evidence-based recommendations.
D. Identify possible precipitating factors related to the infections. The first step in quality improvement is to investigate and assess contributing factors. This helps guide the most appropriate and effective interventions to reduce infection rates.
Correct Answer is A
Explanation
A. Sensation of skin warmth. A warm or flushed sensation is common during cardiac catheterization, especially when contrast dye is injected. This is a normal and temporary response to the dye used in the procedure.
B. Increased salivation. Increased salivation is not a typical reaction during cardiac catheterization. It is not associated with the administration of contrast dye or catheter manipulation.
C. Numbness and tingling of the extremities. Numbness or tingling may indicate compromised circulation or nerve involvement, which is abnormal and should be reported immediately. It may suggest complications like arterial spasm or clot.
D. Headache. Headaches are not expected during a cardiac catheterization. If a headache occurs, especially a severe one, it should be evaluated further, as it could indicate a reaction or another complication.
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