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. Unscrew the pins to cleanse the pin sites: Unscrewing the pins is incorrect as it can compromise the stability of the traction and increase the risk of infection. Pin site care should be performed according to the facility's protocol without disturbing the pins.
B. Remove the weights while turning the client in bed: Removing weights is incorrect as it can disrupt the alignment and effectiveness of the traction. Weights should be left in place to maintain proper traction and alignment.
C. Loosen the rope knots holding the weights for 30 min if the client reports pain: Loosening the rope knots is inappropriate and can interfere with the traction's effectiveness. Pain management should involve assessing the client's comfort and reviewing the traction setup, but not altering the traction itself.
D. Ensure that there is at least 4.5 kg (10 lb) of weight applied to the client's traction: This is correct as maintaining the appropriate amount of weight is crucial for proper skeletal traction. Ensuring that the prescribed weight is applied helps in achieving the desired therapeutic effect.
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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