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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A: This is incorrect because applying lotion between the toes can create a moist environment that promotes fungal growth and infection. The client should apply lotion to the feet but avoid the areas between the toes.

Choice B: This is incorrect because wearing open-toe shoes can expose the feet to injury and infection. The client should wear well-fitting, closed-toe shoes that protect the feet and prevent pressure ulcers.

Choice C: This is correct because wearing cotton socks can help keep the feet dry and prevent fungal infections. Cotton socks also provide cushioning and reduce friction.

Choice D: This is incorrect because rounding the corners of the toenails can cause ingrown nails, which can lead to infection and ulceration. The client should trim the toenails straight across and file any sharp edges.

A. Maintain the client on bed rest. B. Reposition the client. C. Apply a warm, moist compress to the incision area. D. Administer an additional dose of pain medication.

Correct Answer is B

Explanation

Choice A: This is incorrect because maintaining the client on bed rest can increase the risk of complications such as pneumonia, thromboembolism, or pressure ulcers. The nurse should encourage early ambulation and frequent position changes to promote healing and prevent complications.

Choice B: This is correct because repositioning the client can help relieve pressure and discomfort from the incision site. The nurse should assist the client to change positions every 2 hours and use pillows or splints to support the incision.

Choice C: This is incorrect because applying a warm, moist compress to the incision area can interfere with wound healing and increase the risk of infection. The nurse should keep the incision site clean and dry and follow the provider's orders for dressing changes.

Choice D: This is incorrect because administering an additional dose of pain medication is not necessary when the client reports a pain level of 2 on a scale of 0 to 10. The nurse should monitor the client's pain level and administer pain medication as prescribed and as needed.

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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?

Nursing Test Bank

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