A nurse is assisting with teaching a client who is preoperative for a sigmoid colostomy. Which of the following statements should the nurse include?
You should expect your stoma to be a purple color.
Your colostomy will not produce formed stool.
The end of the stoma will be painful after this procedure.
You will have a stoma in your left lower abdomen.
The Correct Answer is D
Choice A reason: You should not expect your stoma to be a purple color. A purple stoma indicates ischemia or necrosis, which are serious complications that require immediate medical attention. A healthy stoma should be pink or red and moist.
Choice B reason: Your colostomy will produce formed stool, depending on the location of the colostomy. A sigmoid colostomy is located in the lower part of the large intestine, where most of the water is absorbed from the stool. Therefore, the stool from a sigmoid colostomy will be more solid and regular than from other types of colostomies.
Choice C reason: The end of the stoma will not be painful after this procedure. The stoma is made from the lining of the intestine, which does not have nerve endings that sense pain. However, the skin around the stoma may be sore or irritated from the surgery or the appliance.
Choice D reason: You will have a stoma in your left lower abdomen. A sigmoid colostomy is created by bringing the end of the sigmoid colon, which is the last segment of the large intestine, through an opening in the left lower quadrant of the abdomen. The stoma is then attached to the skin and covered with an appliance that collects the stool.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Storing oxygen tanks upright is not a necessary instruction for home oxygen therapy. Oxygen tanks can be stored horizontally or vertically, as long as they are secured and away from heat sources.
Choice B reason: Using petroleum-based ointments to moisturize lips is not advisable for clients who use home oxygen therapy. Petroleum-based products can ignite in the presence of oxygen and cause burns. The nurse should recommend water-based products instead.
Choice C reason: Keeping oxygen tanks 4 feet away from an electric stove is a safety measure for home oxygen therapy. Oxygen is a flammable gas and can cause a fire or explosion if exposed to heat or sparks. The nurse should also instruct the client to avoid smoking, candles, and other open flames.
Choice D reason: Choosing a wool blanket when using oxygen is not a good idea for home oxygen therapy. Wool is a synthetic material that can generate static electricity and ignite oxygen. The nurse should suggest cotton or other natural fabrics instead.
Correct Answer is B
Explanation
The correct answer is b. Decreased deep tendon reflexes.
Choice A: Wheezing
Reason: Wheezing is typically associated with respiratory conditions such as asthma, chronic obstructive pulmonary disease (COPD), or allergic reactions. It is not a common manifestation of hyperkalemia. Hyperkalemia primarily affects the muscular and cardiovascular systems rather than the respiratory system.
Choice B: Decreased deep tendon reflexes
Reason: Hyperkalemia can cause neuromuscular symptoms, including muscle weakness and decreased deep tendon reflexes. High potassium levels interfere with the normal function of muscle cells and nerves, leading to these symptoms. This is a direct result of the altered action potentials in neurons caused by elevated potassium levels.
Choice C: Hypoactive bowel sounds
Reason: Hypoactive bowel sounds are generally associated with conditions that cause decreased gastrointestinal motility, such as ileus or bowel obstruction. While hyperkalemia can affect muscle function, it is more likely to cause hyperactive bowel sounds due to increased gastrointestinal motility rather than hypoactive sounds.
Choice D: Cerebral edema
Reason: Cerebral edema is swelling of the brain and is not a typical manifestation of hyperkalemia. It is more commonly associated with conditions such as traumatic brain injury, stroke, or severe infections. Hyperkalemia primarily affects the heart and muscles.
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