A nurse is collecting data from a client who is postoperative following placement of a colostomy in the ascending colon. In which of the following locations should the nurse expect to find the stoma?
A
B
C
The Correct Answer is A
A. Right upper quadrant is correct. A colostomy placed in the ascending colon is typically located in the right upper quadrant of the abdomen. The ascending colon runs along the right side of the abdomen, so the stoma will be located in that region.
B. Left lower quadrant is incorrect. The left lower quadrant is typically where the descending colon or sigmoid colon are located, so a colostomy placed here would be for those regions, not the ascending colon.
C. Left upper quadrant is incorrect. The left upper quadrant contains parts of the stomach, spleen, and pancreas, but not the ascending colon. A colostomy in the ascending colon would not be located here.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The client's heart rate has increased to 110/min is incorrect. While an increased heart rate can indicate pain, it can also be caused by other factors such as anxiety, dehydration, or fever. Heart rate alone is not the most specific or reliable indicator for the need for analgesia.
B. The client grimaces when changing positions is a possible sign of discomfort, but the level of pain cannot be accurately assessed from facial expressions alone. This may suggest mild to moderate pain but does not provide a clear numerical indication of the client's pain level.
C. The client reports pain as 7 on a scale of 0 to 10 is correct. The pain scale is a more direct and reliable measure of the client's pain experience. A rating of 7 indicates moderate to severe pain, which justifies the need for analgesic intervention.
D. The client demonstrates a decreased attention span could be related to pain or discomfort, but it may also result from other causes, such as fatigue, emotional stress, or medication side effects. This is not as definitive as a self-reported pain level.
Correct Answer is D
Explanation
A. "Once my health care proxy is in place, I relinquish my right to make my own decisions" is incorrect. A health care proxy only comes into effect when the individual becomes incapacitated and unable to make decisions. Until then, the client retains the right to make their own decisions.
B. "My health care proxy designee is not able to sign a consent form on my behalf" is incorrect. The health care proxy designee is authorized to make decisions about medical treatment, which includes signing consent forms on the client’s behalf if the client is unable to do so.
C. "If I have a health care proxy, then I do not need to have a living will" is incorrect. A living will and a health care proxy are separate documents. A living will specify a person’s wishes regarding medical treatments in case they are unable to communicate, while a health care proxy designates someone to make decisions on their behalf. Both can be used together.
D. "I do not need to name a relative as my designee in my health care proxy" is correct. The designee does not have to be a relative. The client can choose anyone they trust to make healthcare decisions on their behalf when they are unable to do so.
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