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. A padded tongue blade: A padded tongue blade is not recommended as it can cause injury to both the client and the nurse. It is a common misconception that it should be used during a seizure, but it does not prevent injury.
B. Anticonvulsant medication: While important for managing seizures, anticonvulsant medication is not an equipment item to be placed at the bedside. It is typically administered as per the prescription and monitored by healthcare providers.
C. A nasogastric tube: A nasogastric tube is not relevant for seizure precautions and is used for different medical purposes, such as feeding or gastric decompression.
D. A suction machine: This is correct as a suction machine is essential to clear the airway in case of aspiration during or after a seizure. It helps in maintaining airway patency and preventing complications.
Correct Answer is D
Explanation
A. Pork sausage with sautéed peppers: Pork sausage is typically high in sodium and saturated fats, which can contribute to increased blood pressure.
B. Beef bouillon with crackers: Beef bouillon is high in sodium, which can elevate blood pressure, making it an unsuitable choice for someone with hypertension.
C. A ham sandwich on rye bread: Ham is high in sodium, and consuming it can negatively impact blood pressure control.
D. Broiled cod with broccoli: This is correct as both broiled cod and broccoli are low in sodium and beneficial for blood pressure control. This choice aligns with dietary recommendations for managing hypertension.
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