A nurse is assisting with postoperative care of a patient who had surgery for creation of a colostomy 24 hours ago. Which findings should the nurse report to the provider?
The skin around the patient’s stoma is bulging.
The stoma protrudes 2 cm (0.8 in) above the patient’s abdominal wall.
The patient’s stoma is moist and beefy red.
The patient has had no fecal output from the stoma.
The Correct Answer is D
Choice A rationale
Bulging skin around the stoma can be a sign of a hernia, but it’s not uncommon in the early postoperative period. It should be monitored, but it’s not typically a cause for immediate concern.
Choice B rationale
A stoma that protrudes 2 cm (0.8 in) above the abdominal wall is considered normal. The stoma should protrude above the skin to prevent stool from coming into contact with the skin, which can cause irritation and breakdown.
Choice C rationale
A stoma that is moist and beefy red is a sign of a healthy stoma. This indicates that the stoma has a good blood supply and is not ischemic or necrotic.
Choice D rationale
No fecal output from the stoma 24 hours after surgery could indicate a blockage or other complication and should be reported to the provider immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Administering 5 mL of the available medication would only provide 12.5 mg of diphenhydramine, which is half the required dose. Therefore, this is not the correct choice.
Choice B rationale
The available medication is diphenhydramine syrup 12.5 mg/5 mL. To administer the required dose of 25 mg, the nurse would need to give 10 mL of the syrup. This is because 25 mg (required dose) divided by 12.5 mg (dose per 5 mL) equals 2. Therefore, 2 times 5 mL equals 10 mL. This is the correct choice as it provides the exact required dose.
Choice C rationale
Administering 15 mL of the available medication would provide 37.5 mg of diphenhydramine, which is more than the required dose. Therefore, this is not the correct choice.
Choice D rationale
Administering 20 mL of the available medication would provide 50 mg of diphenhydramine, which is double the required dose. Therefore, this is not the correct choice.
Correct Answer is A
Explanation
Choice A rationale
Diltiazem is a calcium channel blocker used to treat high blood pressure and prevent chest pain (angina). It works by relaxing the blood vessels so the heart does not have to pump as hard. It also increases the supply of blood and oxygen to the heart. The sustained-release tablets are designed to release the medication slowly in the body. Therefore, patients are advised to consume the medication in its entirety. Crushing, chewing, or breaking the tablet would cause too much of the drug to be released at one time.
Choice B rationale
While it’s generally a good idea to store medications in a cool, dry place, specific storage instructions for diltiazem sustained-release tablets are not typically emphasized. The focus is more on the method of consumption.
Choice C rationale
Grapefruit and grapefruit juice may interact with diltiazem and lead to potentially dangerous effects. Discuss the use of grapefruit products with your doctor. Therefore, it’s not advisable to accompany the medication with grapefruit juice.
Choice D rationale
Diltiazem can be taken with or without food. If it upsets the patient’s stomach, it can be taken with food. However, it’s not a mandatory instruction that the medication must be administered during meals.
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