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.)
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 C
Explanation
A. Encouraging the client to urinate every 2 hr is not appropriate in this situation because the client is receiving continuous bladder irrigation (CBI), and the urinary catheter is meant to drain continuously. The issue is likely related to a blockage or clot in the catheter, not the need for the client to urinate.
B. Securing the urinary catheter to the upper left quadrant is not appropriate because the catheter should be positioned properly to allow for proper drainage. Securing it in an inappropriate location could cause kinks or obstructions.
C. Using 0.9% sodium chloride to perform an intermittent bladder irrigation is the correct action. The client’s scant amount of fluid and bladder spasms suggest that the catheter may be blocked, likely by a clot. Performing an intermittent irrigation with saline can help clear any obstructions in the catheter and restore proper drainage.
D. Applying a cold compress to the suprapubic area is not appropriate for treating bladder spasms caused by a potential obstruction. The priority action is to clear the catheter and ensure proper drainage.
Correct Answer is D
Explanation
A. A sore throat is a common and expected side effect following extubation. It typically resolves on its own and does not require immediate intervention.
B. Rhonchi are low-pitched, rattling sounds that are usually caused by the presence of mucus in the larger airways. While they can indicate airway obstruction, they are not as urgent as stridor.
C. A SaO2 of 92% is slightly below the normal range (typically 95-100%), but it is not an immediate emergency. The nurse should continue monitoring oxygen levels and intervene if they drop further.
D. Stridor is a high-pitched, wheezing sound caused by obstruction or narrowing of the upper airway. It is a medical emergency and requires immediate intervention to prevent complete airway obstruction.
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