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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Apply sterile gloves prior to bathing the client.: Clean, non-sterile gloves are sufficient for personal hygiene unless there is contact with broken skin or body fluids.
B. Replace the top linens with a bath blanket.: A bath blanket provides warmth and maintains the client's privacy/modesty while the top linens are being laundered.
C. Apply clean linens to the bed before bathing the client.: Linens should be changed after the bath to ensure the new linens stay dry and clean.
D. Fill the basin with hot water.: Water should be warm (usually 43°C to 46°C or 110°F to 115°F) to prevent burns and skin irritation.
Correct Answer is D
Explanation
A. Bake with white flour.: White flour is refined and low in fiber, which contributes to constipation. Whole-grain flour is preferred.
B. Use a laxative every day.: Daily laxative use can lead to dependency and a "lazy bowel," worsening chronic constipation over time.
C. Take a calcium supplement.: Calcium supplements are actually known to cause or worsen constipation.
D. Consume probiotic sources.: Probiotics (found in yogurt, kefir, or supplements) help regulate gut flora and improve intestinal motility, which can alleviate chronic constipation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.