A nurse is preparing a preoperative patient for a sigmoid colostomy. What information should the nurse include in the discussion?
The stoma will be located in the lower left abdomen.
The stoma may appear purple.
The colostomy will not produce formed stool.
The end of the stoma may be painful after the procedure.
The Correct Answer is A
Choice A rationale
The stoma for a sigmoid colostomy is typically located in the lower left abdomen. This is because the sigmoid colon is a part of the large intestine that is located in the lower left quadrant of the abdomen.
Choice B rationale
A stoma should appear pink or red and moist. A purple stoma could indicate a lack of blood supply, which is a medical emergency.
Choice C rationale
A sigmoid colostomy will produce formed stool because the sigmoid colon is the last part of the colon, where water is absorbed and stool is formed.
Choice D rationale
The end of the stoma (the part that sticks out from the abdomen) should not be painful after the procedure. If a patient experiences pain, it could indicate a complication such as a blockage or infection.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Discarding any residual gastric contents before administering the tube feeding is not necessary and could lead to unnecessary loss of nutrients and electrolytes.
Choice B rationale
Positioning the patient in a low Fowler’s position is not the optimal position for administering a tube feeding. The patient should be in an upright position to reduce the risk of aspiration.
Choice C rationale
Testing the pH of the gastric aspirate is an important step before administering a tube feeding. This helps to verify that the feeding tube is in the stomach and not in the lungs.
Choice D rationale
Warming the feeding solution to body temperature is not necessary and could potentially lead to bacterial growth in the feeding solution.
Correct Answer is B
Explanation
Choice A rationale
While observing the patient’s respiratory status is important in all patient care, it is not the priority action in this case. The patient’s decreased level of consciousness and inability to swallow increase the risk of aspiration, which can lead to respiratory complications.
Choice B rationale
Elevating the head of the patient’s bed 30° to 45° is the priority action. A patient who has a decreased level of consciousness and an inability to swallow is at risk for aspiration. Lying down also increases this risk. The priority action by the nurse is to keep the head of the bed elevated to promote gastric emptying and reduce the risk of aspiration.
Choice C rationale
Monitoring intake and output every 8 hours is important for assessing the patient’s hydration status and nutritional needs. However, it is not the priority action in this case. The risk of aspiration due to the patient’s decreased level of consciousness and inability to swallow takes precedence.
Choice D rationale
Checking residual volume every 4 to 6 hours is a standard practice when administering continuous enteral feedings through a gastrostomy tube. It helps to ensure that the patient is tolerating the feedings and not at risk for aspiration due to high gastric residuals. However, in this case, the priority is to prevent aspiration by elevating the head of the bed.
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