In preparing to perform colostomy care, the nurse observes that a client's colostomy stoma has become a dark red to bluish color. Which action should the nurse implement?

Remove the drainage bag and apply antibiotic ointment around the stoma.

Apply a pulse oximeter to determine the client's oxygen saturation level.

Replace the colostomy supplies with non-latex hypoallergenic supplies.

Notify the healthcare provider of the appearance of the stoma immediately.

Answer and Explanation

The Correct Answer is D

A. Applying antibiotic ointment is not appropriate for this situation as the issue is likely compromised blood flow, not infection.
B. Checking oxygen saturation is not related to the color change of the stoma.
C. Switching to non-latex supplies is important for clients with latex allergies but is not relevant to the immediate problem.
D. A dark red to bluish color of the stoma suggests compromised blood flow and possible ischemia, which requires immediate medical attention. The nurse should notify the healthcare provider immediately to address this potentially serious complication.

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Correct Answer is A

Explanation

A. Dopamine, a sympathomimetic agent, can cause significant changes in blood pressure. Monitoring blood pressure every 15 minutes is crucial to assess the client's response to the medication and to detect any adverse effects, such as hypertension or hypotension, promptly.
B. Monitoring CBC is important but not as immediately critical in this situation as monitoring blood pressure.
C. While reviewing creatinine and BUN results is important for overall kidney function, it is not the most immediate priority when administering dopamine for shock.
D. Measuring urinary output is important for assessing renal perfusion but should be done more frequently than daily in a client receiving dopamine for shock.

A. An area of erythema that is painful to touch. B. Shallow open ulcer with a red pink wound bed. C. A deep pocket of infection and necrotic tissues. D. Visible subcutaneous tissue with sloughing.

Correct Answer is B

Explanation

A. A stage 2 pressure injury is more than just erythema; it involves partial-thickness skin loss.
B. A stage 2 pressure injury presents as a shallow open ulcer with a red or pink wound bed, indicating partial-thickness loss of dermis.
C. A deep pocket of infection and necrotic tissue describes a stage 3 or 4 pressure injury, not stage 2.
D. Visible subcutaneous tissue and sloughing are characteristics of stage 3 or 4 pressure injuries, not stage 2.

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In preparing to perform colostomy care, the nurse observes that a client's colostomy stoma has become a dark red to bluish color. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is in shock is receiving a continuous IV infusion of a sympathomimetic dopamine. Which intervention should the nurse include in this client's plan of care?

Correct Answer is A

Explanation

During the shift change report, the nurse is told that a client has a stage 2 pressure injury. Which ulcer appearance is most likely to be observed?

Correct Answer is B

Explanation

A client who is taking an oral contraceptive receives a new prescription for erythromycin. Which instruction should the nurse provide to the client?

The nurse is planning discharge teaching for a client with type 2 diabetes mellitus who has a new prescription for insulin glargine. Which action should the nurse plan to Include in the discharge teaching?

The nurse is preparing a bladder irrigation for an adult client who has a long-term indwelling urinary catheter. The urine is cloudy with fibrin clots and sediment. Which intervention should the nurse implement?

A male client has been receiving the antibiotic gentamicin sulfate, IV piggyback every 12 hours for several days. Which observation by the nurse indicates that the client may be experiencing an adverse effect of gentamicin? Reference Range: White Blood Cell [5000 to 10,000/mm3 (5 to 10 x 109/L)]

When entering a client's room to assess vital signs, the nurse finds the client crying. After allowing the client to express feelings, which intervention should the nurse implement?

To detect common untoward effects of phenytoin, the nurse should assess a client with a seizure disorder for which sign or symptom?

After receiving large doses of chlorpromazine for two weeks, a client begins to develop spasms of the neck and back. Which action should the nurse take?