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.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Applying moist heat to the incision while in bed is not an appropriate instruction, as it can increase the risk of infection, bleeding, or swelling at the site. The nurse should instruct the client to keep the incision dry and covered with a sterile dressing.
Choice B reason: Performing range of motion by adducting the hip is not an appropriate instruction, as it can cause dislocation or damage to the prosthesis. The nurse should instruct the client to avoid crossing their legs or turning their toes inward and to use an abduction pillow or wedge between their legs.
Choice C reason: Sitting in a straight-backed chair is an appropriate instruction, as it can prevent flexion contractures and promote circulation and healing in the hip joint. The nurse should instruct the client to use a raised toilet seat and a chair with armrests and avoid sitting for longer than 45 min at a time.
Choice D reason: Cleansing the surgical incision with hydrogen peroxide is not an appropriate instruction, as it can irritate or damage the tissue and delay wound healing. The nurse should instruct the client to use mild soap and water or saline solution to clean the incision and pat it dry gently.
Correct Answer is D
Explanation
Choice A reason: PaO2 85 mmHg is within the normal range of 80 to 100 mmHg and does not indicate any hypoxemia or oxygen deficiency.
Choice B reason: pH 7.47 is within the normal range of 7.35 to 7.45 and does not indicate any acid-base imbalance.
Choice C reason: HCO3 25 mEq/L is within the normal range of 22 to 26 mEq/L and does not indicate any metabolic disturbance.
Choice D reason: PaCO2 55 mmHg is above the normal range of 35 to 45 mmHg and indicates respiratory acidosis, which is a condition where the lungs cannot eliminate enough carbon dioxide and the blood becomes too acidic. This can be caused by pneumonia, which can impair gas exchange and ventilation.
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