A nurse is assisting with postoperative care of a client who had surgery for creation of a colostomy 24 hr ago. Which of the following findings should the nurse report to the provider?
The skin around the client's stoma is bulging.
The client has had no fecal output from the stoma.
The stoma protrudes 2 cm (0.8 in) above client's abdominal wall.
The client's stoma is moist and beefy red.
The Correct Answer is B
A. The skin around the client's stoma is bulging: While bulging skin can be concerning, it is often a normal postoperative finding as the stoma settles into its new position. However, further evaluation may be needed if other symptoms are present.
B. The client has had no fecal output from the stoma: This is correct as the absence of fecal output 24 hours postoperatively could indicate a potential issue such as a blockage or anastomotic failure, which requires prompt evaluation by the provider.
C. The stoma protrudes 2 cm (0.8 in) above client's abdominal wall: This is generally considered normal. The stoma should protrude slightly to ensure it is not retracted and is functioning properly.
D. The client's stoma is moist and beefy red: This is a normal finding. A healthy stoma should be moist and beefy red, indicating good blood flow and viability.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "My urine comes out whenever I sneeze": This indicates stress incontinence, where urine leakage occurs with physical activities that increase abdominal pressure.
B. "It seems like my bladder empties without warning": This suggests urge incontinence, characterized by a sudden and intense urge to urinate.
C. "I have urine incontinence whenever I take a diuretic": This statement is more related to the effects of diuretics rather than a specific type of urinary incontinence.
D. "My urine seems to dribble out frequently": This is characteristic of overflow incontinence, where the bladder becomes overfilled and urine dribbles out due to inadequate emptying.
Correct Answer is A
Explanation
A. Use the client's left arm to obtain blood samples: This is correct as using the arm on the opposite side of the mastectomy helps avoid additional stress or injury to the affected arm, which can help prevent lymphedema.
B. Keep both arms below the level of the client's heart: This is not recommended as elevating the affected arm can help reduce swelling and promote lymphatic drainage.
C. Limit range-of-motion exercises with the affected arm: This is incorrect as range-of-motion exercises are important to prevent stiffness and promote circulation, which helps reduce the risk of lymphedema.
D. Obtain blood pressure readings using the client's right arm: This is incorrect as obtaining blood pressure on the affected side could increase the risk of lymphedema.
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