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 B
Explanation
A. "I will need to empty my bladder regularly and completely." Regular and complete bladder emptying helps to flush bacteria from the urinary tract, reducing the risk of UTIs. This statement indicates correct understanding and does not need further teaching.
B. "I will need to wipe my perineal area from back to front after urination." Wiping from back to front can introduce bacteria from the rectal area into the urethra, increasing the risk of UTIs. The correct practice is to wipe from front to back. This statement indicates a need for further teaching.
C. "I need to drink 8 cups of liquid each day." Adequate fluid intake helps to dilute urine and flush out bacteria, reducing the risk of UTIs. This statement is correct and does not need further teaching.
D. "I will need to drink apple cider vinegar each day." Although apple cider vinegar is sometimes suggested as a home remedy, there is no strong evidence supporting its use in UTI prevention. However, this statement does not indicate a harmful practice and may not necessarily need further teaching unless it is replacing evidence-based methods. The key incorrect statement is related to wiping technique.
Correct Answer is C
Explanation
A. Apply friction when drying the client's skin. Friction can damage the skin, especially in clients with incontinence who are at risk for skin breakdown.
B. Use soap to clean the client's skin. Soap can be drying and irritating to the skin. pH-balanced cleansers are preferred to maintain skin integrity.
C. Apply a barrier cream to the client's skin. Barrier creams protect the skin from moisture, reducing the risk of skin breakdown and irritation from incontinence.
D. Use hot water to clean the client's skin. Hot water can dry out and damage the skin. Warm water should be used instead to gently clean the skin.
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