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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
A. Place each sleeve under each leg with the opening at the calf: This is incorrect; the correct placement is with the opening at the thigh and the sleeve wrapped around the entire leg.
B. Ensure two fingers fit between the leg and the sleeve: This is correct as it ensures that the SCD sleeve is properly fitted and not too tight, allowing for effective compression without restricting blood flow.
C. Wrap excess tubing to the side of each leg: This is incorrect because excess tubing should not be wrapped around the leg; it should be managed to avoid kinks and ensure proper functioning of the device.
D. Ensure pressure of the device is at 25 mm Hg: This is not specific enough for all devices; the pressure setting should be according to the manufacturer's guidelines and the client's needs, often ranging between 30 and 40 mm Hg for optimal effectiveness.
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