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A nurse is preparing to receive a client from surgery following a transverse colon resection with colostomy placement. The nurse should expect to assess the stoma at which of the following locations? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
Answer and Explanation

The Correct Answer is "{\"xRanges\":[53.828125,93.828125],\"yRanges\":[164,204]}"

A. The stoma from a transverse colon resection with colostomy placement is typically located in the right iliac fossa, which is the lower right quadrant of the abdomen. This is where the transverse colon is most often brought to the surface for colostomy placement. It allows for easier access and drainage postoperatively.

B. The epigastric area, which is located above the umbilicus, is not a typical location for a colostomy stoma. This area is more commonly associated with upper abdominal organs such as the stomach and liver.

C. The left iliac fossa is generally where a descending or sigmoid colostomy would be placed, rather than a transverse colon resection. This location would be expected for colostomies created from the descending colon, not the transverse colon.


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Related Questions

Correct Answer is D

Explanation

A. Clients in protective isolation require more frequent temperature monitoring due to their high risk for infection. Monitoring once every 6 hours may not be sufficient to detect early signs of infection.
B. An N95 respirator is necessary for airborne precautions (e.g., tuberculosis) but is not required for protective isolation unless indicated for another reason.
C. While disposable plates and utensils may be used, they are not a primary requirement for infection prevention in protective isolation. Properly cleaned and sanitized utensils are generally safe.
D. Protective isolation requires positive-pressure airflow to prevent airborne pathogens from entering the client’s room, reducing the risk of infection in immunocompromised individuals.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"},"E":{"answers":"A"}}

Explanation

Rationale

Interpretation of Assessment Findings:

  • Urine ketones:
    • DKA
      The presence of urine ketones is a hallmark of diabetic ketoacidosis (DKA), as it indicates the body is breaking down fat for energy due to insufficient insulin. Ketones are typically not present in hyperglycemic-hyperosmolar state (HHS).
  • Blood glucose greater than expected reference range:
    • DKA
    • HHS
      Elevated blood glucose levels are consistent with both DKA and HHS. However, blood glucose levels tend to be higher in HHS than in DKA, often exceeding 600 mg/dL in HHS.
  • Skin turgor:
    • DKA
    • HHS
      Decreased skin turgor indicates dehydration, which is a common feature in both DKA and HHS due to osmotic diuresis caused by hyperglycemia.
  • Creatinine greater than expected reference range:
    • DKA
    • HHS
      Elevated creatinine reflects impaired renal function, often due to dehydration or acute kidney injury, which can occur in both DKA and HHS.
  • Blood pH:
    • DKA
      A blood pH of 7.30 indicates metabolic acidosis, a defining feature of DKA. Blood pH is typically normal in HHS because it does not involve significant ketoacidosis.

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