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
The Correct Answer is A
The correct answer is Choice A.
Choice A rationale: A pale blue stoma indicates compromised perfusion or necrosis. This is a surgical emergency requiring immediate assessment to prevent tissue death and systemic complications.
Choice B rationale: Continuous drainage may reflect normal output depending on stoma type. It’s not immediately life-threatening and doesn’t require urgent intervention.
Choice C rationale: Fecal contamination is expected with colostomies. While hygiene is important, this does not indicate a critical issue needing priority care.
Choice D rationale: A beefy red, moist stoma is the expected healthy appearance of a functioning colostomy. No intervention is needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A This is considered a normal abdominal assessment. The abdomen is soft and not distended, and bowel sounds are present and normal in all four quadrants.
Choice B Abdominal distension and firmness may indicate possible bowel obstruction or other gastrointestinal issues. Hypoactive bowel sounds suggest reduced motility, which is not normal.
Choice C Abdominal distension with hyperactive bowel sounds may indicate gastrointestinal irritation or increased motility, which is not normal.
Choice D A firm abdomen with hypoactive bowel sounds is not typical of a normal abdominal assessment.
Correct Answer is D
Explanation
Choice A Alcohol swabs may be too harsh and irritating for the delicate skin around the stoma. Mild soap and water are preferred for cleaning.
Choice B Tap water alone may not be sufficient for removing debris and ensuring proper cleanliness around the stoma. Mild soap and water are preferred for cleaning.
Choice C Iodine may be too harsh and irritating for the peristomal skin. Mild soap and water are preferred for cleaning.
Choice D Mild soap and water are the best choice for cleaning around the colostomy stoma as they effectively remove debris and cleanse the area without being overly harsh on the skin.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.