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.

Answer and Explanation

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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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"E"}

Explanation

1. Bumetanide 1 mg IV stat: The client’s vital signs show hypotension (blood pressure 88/54 mm Hg) and tachycardia (heart rate 104/min). The skin is cool and moist, and capillary refill is delayed, suggesting possible fluid overload or heart failure. Bumetanide is a potent diuretic used to address fluid overload and reduce the heart's workload.

2. Packed red blood cells: The client’s urine output is low (110 mL over 6 hours), which, combined with signs of hypotension and tachycardia, may indicate significant blood loss or anemia. Administering packed red blood cells can help correct anemia and improve blood volume.

A. Clean the client's finger with hexachlorophene. B. Apply the first drop of blood to the test strip. C. Hold the client's finger in a dependent position. D. Prick the central tip of the client's finger.

Correct Answer is C

Explanation

A. Clean the client's finger with hexachlorophene: Hexachlorophene is not recommended for cleaning the skin before blood glucose testing; a mild soap and water or an alcohol swab is typically used.
B. Apply the first drop of blood to the test strip: The first drop of blood is often not used due to potential contamination; the nurse should usually wipe away the first drop and use the second one.
C. Hold the client's finger in a dependent position: This is correct as holding the finger downward can help increase blood flow to the fingertip, facilitating easier blood collection.
D. Prick the central tip of the client's finger: Pricking the central tip can be painful; the sides of the fingertip are preferred for less discomfort and to avoid nerve endings.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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