A nurse is assessing a client who has a colostomy. Which of the following findings show the nurse report to the provider?
The skin around the stoma is red.
The ostomy is draining frequently.
The stool is yellow-green.
The stoma is pale in color.
The Correct Answer is D
A. The skin around the stoma is red: Redness around the stoma may indicate skin irritation, which is common but typically managed with proper skin care and is not always an urgent concern. However, if the redness is severe or associated with other symptoms, it should be monitored. Reporting may be necessary if it worsens.
B. The ostomy is draining frequently: Frequent drainage may be expected depending on the location of the colostomy and the client’s diet. While it should be monitored, frequent drainage alone does not necessarily indicate a problem that needs to be reported.
C. The stool is yellow-green: The color of stool can vary depending on diet, the location of the colostomy, and bile presence. Yellow-green stool is often expected in higher colostomies and may not need to be reported unless it is a sudden change.
D. The stoma is pale in color: A pale or dusky stoma can indicate compromised blood flow, which is a serious concern and should be reported to the provider immediately. A healthy stoma should be pink or red.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Reflex incontinence: Reflex incontinence occurs when the bladder muscle contracts and urine leaks out (often in large amounts) without any warning or urge. This is common in clients with nerve damage or spinal cord injuries, making it the correct answer.
B. Urge incontinence: Urge incontinence is characterized by a sudden, intense urge to urinate followed by involuntary urine loss. It is often associated with an overactive bladder, not nerve damage.
C. Stress incontinence: Stress incontinence involves urine leakage during physical activity or exertion (e.g., coughing, sneezing) that increases abdominal pressure. It is not typically related to nerve damage.
D. Overflow incontinence: Overflow incontinence occurs when the bladder is unable to empty properly, leading to dribbling of urine. It is often seen in conditions where the bladder muscles are weak or there is an obstruction. While it can be related to nerve damage, reflex incontinence is more accurate for this scenario.
Correct Answer is B
Explanation
A. Dilute each medication with 10 mL of tap water. Typically sterile or distilled water is preferred for diluting medications to reduce the risk of infection.
B. Flush the NG feeding tube with 30 mL of water immediately following medication administration. Flushing the tube before and after medication administration helps ensure the tube remains patent and the medication is fully delivered.
C. Maintain the head of the bed in a flat position for 30 minutes following medication administration. The head of the bed should be elevated to at least 30-45 degrees to prevent aspiration during and after medication administration.
D. Mix the three medications together prior to administering. Medications should not be mixed together unless compatibility has been confirmed, as mixing can cause interactions or blockages in the tube.
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