A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?

The stoma appears dark in color.

The stoma bleeds lightly when touched.

The stoma is draining a small amount of liquid stool.

The stoma protrudes slightly from the abdomen.

Answer and Explanation

The Correct Answer is A

A. The stoma appears dark in color.: A healthy stoma should be moist and reddish-pink. A dark (purple, black, or dusky) stoma indicates ischemia or poor perfusion and must be reported immediately to prevent tissue death.

B. The stoma bleeds lightly when touched.: This is a common and expected finding, as stoma tissue is highly vascular and fragile, especially in the early postoperative period.

C. The stoma is draining a small amount of liquid stool.: This is an expected finding 2 days postoperatively as the bowel begins to resume function.

D. The stoma protrudes slightly from the abdomen.: A slight protrusion (budding) is normal and helps the stool fall into the collection pouch rather than sitting on the skin.

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Correct Answer is A

Explanation

A. Decrease background noise.: Eliminating competing sounds (TV, hallway noise, fans) makes it easier for the client to focus on the nurse’s voice and prevents sound distortion.

B. Speak in a loud voice.: Incorrect. Shouting can distort the sound of words and often raises the pitch of the voice, which is usually the frequency most difficult for those with hearing loss to hear.

C. Talk at a rapid rate.: Incorrect. The nurse should speak slowly and clearly to allow the client time to process the information and potentially read lips.

D. Use short phrases.: While clarity is good, using "short phrases" can come across as "baby talk" or patronizing. Speaking in normal, clear sentences is preferred unless the client has a cognitive impairment.

A. Suctioning a tracheostomy for a client who has a recent head injury B. Providing postmortem care for a client who has just died C. Changing a peripheral IV dressing for a client who is postoperative D. Administering vaginal cream to a client who has a vaginal infection

Correct Answer is B

Explanation

A. Suctioning a tracheostomy for a client who has a recent head injury: Incorrect. This is an invasive procedure requiring clinical judgment and sterile technique; it must be performed by a nurse.

B. Providing postmortem care for a client who has just died: Postmortem care (cleaning the body, positioning) is within the scope of practice for an AP.

C. Changing a peripheral IV dressing for a client who is postoperative: Assessment of an IV site and sterile dressing changes require the skills of a licensed nurse.

D. Administering vaginal cream to a client who has a vaginal infection: Medication administration is generally restricted to licensed personnel (RN/LPN).

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A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?

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Naxlex Comprehensive Predictor Exams

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