A nurse is caring for a client who is postoperative following the placement of a colostomy. Which of the following findings indicates that the colostomy is functioning properly?
Passing of flatus
Stoma is pinkish-red
Tolerating a clear liquid diet
Absent bowel sounds
The Correct Answer is B
Choice A reason: Passing of flatus is not a reliable indicator of colostomy function, as it can occur even when there is an obstruction or ischemia in the bowel.
Choice B reason: Stoma is pinkish-red is a sign of a healthy and well-perfused colostomy, as it indicates that the blood supply to the bowel segment is adequate and there is no necrosis or infection.
Choice C reason: Tolerating a clear liquid diet is not a specific indicator of colostomy function, as it does not reflect the amount or consistency of the stool output.
Choice D reason: Absent bowel sounds are not a normal finding for a colostomy, as they can indicate a paralytic ileus or a bowel obstruction, which can cause complications such as distension, pain, or perforation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Wiping the top of the feeding container with alcohol is not a priority action, as it is not essential for infection control or safety. The nurse should use a sterile technique when opening and handling the feeding container.
Choice B reason: Placing the head of the client's bed at a 30° angle or higher is a priority action, as it can prevent aspiration or regurgitation of the feeding solution into the lungs, which can cause pneumonia or respiratory distress.
Choice C reason: Rinsing the feeding bag with water once the feeding is complete is not a priority action, as it can be done after ensuring that the client has tolerated the feeding well and has no signs of complications.
Choice D reason: Documenting the client's response to the feeding is not a priority action, as it can be done after performing other interventions and assessments that are more urgent and important for the client's well-being.
Correct Answer is C
Explanation
Choice A reason: Taking the medication right before eating breakfast is not an appropriate instruction, as it can reduce the absorption and effectiveness of alendronate, which is a bisphosphonate drug that inhibits bone resorption and increases bone density. The client should take the medication at least 30 min before eating or drinking anything other than water.
Choice B reason: Drinking milk with the medication is not an appropriate instruction, as it can interfere with the absorption and effectiveness of alendronate, which can bind to calcium and other minerals and form insoluble complexes that are excreted in feces. The client should avoid consuming dairy products or supplements that contain calcium, iron, magnesium, or aluminum for at least 30 min after taking the medication.
Choice C reason: Staying upright for 30 to 60 min after taking the medication is an appropriate instruction, as it can prevent esophageal irritation or ulceration that can be caused by alendronate, which can be corrosive to the mucosa if it remains in contact with it for too long. The client should not lie down or bend over until after their first food of the day.
Choice D reason: Chewing the tablets thoroughly is not an appropriate instruction, as it can increase the risk of esophageal irritation or ulceration that can be caused by alendronate, which can be abrasive to the mucosa if it is not swallowed whole with a full glass of water. The client should not crush, break, or dissolve the tablets in any liquid.
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