A patient has undergone a single-barrel descending colon colostomy for the palliative treatment of stage IV colon cancer. The nurse assesses the colostomy stoma to ensure that it is:
Beefy red and moist
Dusky maroon colored
Pale and pink
Pink and dry
The Correct Answer is A
Choice A reason: A healthy stoma should be beefy red and moist, indicating good blood supply and hydration.
Choice B reason: A dusky maroon color could indicate compromised blood supply or ischemia.
Choice C reason: A pale and pink stoma may suggest anemia or reduced blood flow.
Choice D reason: A stoma that is pink and dry could be dehydrated, which is not ideal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Right arm muscle spasms may be uncomfortable but are not as critical as circulatory issues.
Choice B reason: A temperature of 99.9°F (37.7°C) is slightly elevated but not immediately alarming post-surgery.
Choice C reason: Loss of the right radial pulse could indicate a serious complication such as compartment syndrome, which requires urgent atention.
Choice D reason: Pain with arm movement is expected post-surgery but is not as urgent as loss of pulse.
Correct Answer is C
Explanation
Choice A reason: The recovery position is not typically recommended for patients with acute pulmonary edema as it does not facilitate optimal breathing.
Choice B reason: The prone position is not generally recommended for acute pulmonary edema as it may not aid in improving oxygenation or breathing.
Choice C reason: The sitting up position, especially at an angle of 45 degrees or greater, is recommended for patients with acute pulmonary edema as it helps to facilitate breathing and decrease venous return to the heart.
Choice D reason: The Trendelenburg position is not recommended for acute pulmonary edema as it can increase the pressure in the chest and worsen breathing difficulties.
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