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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Positioning the client supine is not a necessary action for the nurse to take, as the client can be in any comfortable position for the catheter removal. The nurse should explain the procedure to the client and provide privacy.

Choice B reason: Cleansing the perineal area with an antiseptic is not a required action for the nurse to take, as the catheter is already sterile and the risk of infection is low. The nurse should wear gloves and use a clean syringe to deflate the balloon.

Choice C reason: Deflating the balloon halfway and then pulling out the catheter is the correct action for the nurse to take, as it ensures that the catheter is removed smoothly and without causing trauma to the urethra. The nurse should apply gentle traction and observe the urine color and amount in the drainage bag.

Choice D reason: Having the client bear down during removal is not a recommended action for the nurse to take, as it can cause discomfort and bleeding. The nurse should instruct the client to relax and breathe normally during the procedure.

A. Numbness of fingers B. Abdominal pain C. Dry skin D. Lethargy

Correct Answer is D

Explanation

Choice A reason: Numbness of fingers is not a sign of respiratory acidosis. It can be caused by other conditions such as peripheral neuropathy, Raynaud's syndrome, or carpal tunnel syndrome.

Choice B reason: Abdominal pain is not a sign of respiratory acidosis. It can be caused by other conditions such as gastritis, appendicitis, or gallstones.

Choice C reason: Dry skin is not a sign of respiratory acidosis. It can be caused by other conditions such as dehydration, eczema, or hypothyroidism.

Choice D reason: Lethargy is a sign of respiratory acidosis, as it indicates a low level of oxygen and a high level of carbon dioxide in the brain. Lethargy is a state of reduced mental and physical activity, which can progress to confusion, coma, or death if not treated.

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A nurse is assisting with teaching a client who is preoperative for a sigmoid colostomy. Which of the following statements should the nurse include?

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Naxlex Comprehensive Predictor Exams

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