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 B
Explanation
The correct answer is choice b. Insert the tip of the enema tube into the rectum pointing towards the umbilicus.
Choice A rationale:
Giving the enema while the patient sits on the toilet is incorrect because it can cause discomfort and does not allow for proper administration of the enema solution.
Choice B rationale:
Inserting the tip of the enema tube into the rectum pointing towards the umbilicus is correct because it follows the natural curvature of the rectum and colon, ensuring effective delivery of the solution.
Choice C rationale:
Having the patient lie on the right side is incorrect. The left lateral position is typically recommended for enema administration as it allows the solution to flow more easily into the sigmoid colon and descending colon.
Choice D rationale:
Chilling the water to a temperature between 75°F and 85°F is incorrect. The enema solution should be warmed to body temperature (around 99°F to 106°F) to avoid causing cramping or discomfort.
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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