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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Secure new tracheostomy ties before removing old ones. Securing the new ties before removing the old ones prevents accidental decannulation of the tracheostomy tube.

B. Use aseptic technique. Aseptic technique should be used to reduce the risk of infection during tracheostomy care.

C. Apply suction when inserting the catheter. Suction should only be applied when withdrawing the catheter, not during insertion, to prevent trauma to the trachea and bronchial tissues.

D. Clean the inner cannula with mild soap and water. The inner cannula should be cleaned with sterile saline or a prescribed solution, not with soap, to avoid irritation and infection.

A. A nonrebreather mask dries a client's mucous membranes. B. Use a nonrebreather mask to deliver low-flow oxygen. C. The reservoir bag on a nonrebreather mask should collapse with exhalation. D. A nonrebreather mask should fit snugly over a client's face.

Correct Answer is D

Explanation

A. "Small electrodes are placed on my scalp." This statement describes an EEG, not the Rinne test. The Rinne test involves a tuning fork, not electrodes. This statement is incorrect.

B. "I will wear earphones during this test." This statement describes an audiometry test, not the Rinne test. The Rinne test uses a tuning fork, not earphones. This statement is incorrect.

C. "A tuning fork is placed on my head." The Rinne test is a hearing test that involves placing a vibrating tuning fork on the mastoid process behind the ear and then comparing the sound conducted through bone to the sound conducted through air.

D. "A small probe is placed inside my ear." This statement describes tympanometry or other tests that involve probes in the ear, not the Rinne test. The Rinne test uses a tuning fork placed on the mastoid bone and near the ear canal. This statement is incorrect.

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A nurse is assessing a client who has a colostomy. Which of the following findings show the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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