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","D","E"]

Explanation

A. Allergies: The client is allergic to latex and penicillin. Since surgery involves the use of gloves, tubing, and catheters (latex) and often includes prophylactic antibiotics (penicillin family), these allergies must be communicated and a "latex-free" environment/alternative antibiotics must be established to prevent anaphylaxis.

B. Oxygen saturation: The client's oxygen saturation is 96%, which is within the normal expected range (95% to 100%). This does not require immediate follow-up prior to the procedure.

C. Pain level: While the pain is high (8/10), this is an expected finding for acute appendicitis. It should be managed, but it is not a barrier to surgery in the same way as safety or legal concerns.

D. Dietary intake: The client reported eating toast at 0600. Surgery requires a client to be NPO (nothing by mouth) for a specific period (usually 6–8 hours) to reduce the risk of aspiration under anesthesia. The surgical team and anesthesiologist must be notified of the 0600 intake.

E. Informed consent: Although the surgeon obtained consent, the nurse notes that the client "expresses concerns about potential complications." If a client expresses doubt or a lack of understanding after signing, the nurse must notify the surgeon to return and provide further clarification before the procedure begins.

F. Blood pressure: The client's blood pressure is stable (124/80 mm Hg) and within normal limits; it does not require follow-up.

A. Apply sterile gloves prior to bathing the client. B. Replace the top linens with a bath blanket. C. Apply clean linens to the bed before bathing the client. D. Fill the basin with hot water.

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","D","E"]

Explanation

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Correct Answer is B

Explanation

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