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 {"dropdown-group-1":"C","dropdown-group-2":"C"}
Explanation
Correct answer: The client is at risk for Aspiration as evidenced by the client's Dysphagia.
i. Aspiration: The client is exhibiting classic signs of dysphagia (difficulty swallowing), specifically "feeling food stuck in their mouth" and a "hoarse vocal quality." When a client cannot swallow effectively, food or liquid can enter the airway instead of the esophagus, leading to aspiration pneumonia.
ii. Dysphagia: This is the clinical term for the symptoms described in the Nurses' Notes (hoarseness and food pocketing). While the client does have a slightly elevated blood pressure and heart rate, these are secondary to the primary safety risk of an impaired airway/swallow reflex.
Correct Answer is A
Explanation
A. "Maintain your arms in a slightly flexed position when using the walker.": The walker should be adjusted so the client's elbows are flexed at approximately 20° to 30°. This allows the client to bear weight through their arms effectively.
B. "Move your right leg forward as you advance the walker.": The walker should be advanced first, followed by the affected (weak) leg, then the stronger leg.
C. "Support yourself with the walker when climbing stairs.": Walkers are generally unsafe for use on stairs; a client should use a handrail and a cane or crutches if stairs are necessary.
D. "Keep your eyes on your feet when ambulating with the walker.": Clients should look forward to maintain balance and avoid obstacles; looking down increases the risk of falls.
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