A nurse is caring for 4 patients each patient has a colostomy bag. Which patient should be seen first and made a priority?

The patient with a pale blue stoma

The patient with a continuous draining stoma

The patient with a stoma that had fecal contents all over it.

The patient with a beefy red, moist stoma

Answer and Explanation

The Correct Answer is C

Choice A A pale blue stoma may indicate a lack of blood supply (ischemia) to the stoma, which is concerning but not as immediately critical as fecal contamination.

Choice B A continuous draining stoma is normal, and there is no indication of an urgent issue in this scenario.

Choice C This patient should be seen first and made a priority as fecal contamination of the stoma can lead to skin irritation, infection, and complications. Immediate cleaning and appropriate care are necessary.

Choice D A beefy red, moist stoma is a healthy stoma appearance and does not indicate an urgent issue.

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Correct Answer is C

Explanation

Choice A Using a cool solution might cause discomfort and could lead to cramping, which is not ideal for an enema administration.

Choice B Boiling the solution is unnecessary and might be unsafe, as it could cause burns or damage the components of the enema.

Choice C Warming the solution to body temperature (around 98.6°F or 37°C) is the appropriate approach, as it ensures patient comfort and reduces the risk of cramping or discomfort.

Choice D Microwaving the solution might lead to uneven heating and could potentially create hot spots, which could cause burns or discomfort for the patient.

A. Shape of abdomen B. Bowel sounds C. Abdominal cramping and discomfort D. Distention of abdomen

Correct Answer is C

Explanation

Choice A The shape of the abdomen is a physical assessment finding and not subjective

information provided by the patient. It involves the nurse's observation of the patient's abdomen during the examination.

Choice B Bowel sounds are also physical assessment findings that involve the nurse listening to the patient's abdomen using a stethoscope.

Choice C This is the correct answer. Abdominal cramping and discomfort are subjective symptoms reported by the patient and are relevant to the patient's bowel elimination status. Choice D Like the shape of the abdomen, the distention of the abdomen is a physical assessment finding and not subjective information provided by the patient.

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A nurse is caring for 4 patients each patient has a colostomy bag. Which patient should be seen first and made a priority?

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Naxlex Comprehensive Predictor Exams

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Explanation

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