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. Pyridostigmine is most effective when taken before meals to improve muscle strength for swallowing. Knowing the client's recent oral intake helps in timing the medication appropriately.
B. Difficulty with urination is not directly related to pyridostigmine use.
C. Trouble sleeping is not typically associated with pyridostigmine.
D. Unexplained weight loss may be related to myasthenia gravis but is not directly relevant to the immediate administration of pyridostigmine.

A. Left carotid pulse volume of 4+; right carotid pulse volume of 0. B. Left carotid artery bruit present; no bruit heard in right carotid artery. C. Left carotid artery has strong pulse; right carotid artery occluded. D. Left carotid artery occlusion present; no occlusion of right carotid artery.

Correct Answer is B

Explanation

A. Pulse volume and bruit are different assessments; pulse volume is not graded in the context of auscultation findings.
B. A bruit is an abnormal sound heard over an artery, indicating turbulent blood flow, often due to stenosis or narrowing. Documenting a "left carotid artery bruit present" accurately reflects the findings.
C. The presence of a bruit does not necessarily mean the pulse is strong or that there is occlusion.
D. A bruit indicates turbulent flow, not necessarily complete occlusion.

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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 with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain to prior to administering the medication?

Correct Answer is A

Explanation

In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

Correct Answer is B

Explanation

The nurse is caring for a client who is taking the mood stabilizer divalproex sodium. Which laboratory value is most important for the nurse to monitor?

An older client is admitted to the medical-surgical unit after falling and fracturing the left hip. The nurse is reviewing written preoperative instructions with the client and spouse. Which action should the nurse implement while providing these instructions?

An older adult client reports noticing increased difficulty hearing over the past year. The client explains that words often sound garbled and the end of sentences are often missed. Which follow-up question is best for the nurse to ask?

An older client who is experiencing urinary incontinence is brought to the clinic with increased confusion. The nurse observes serous drainage from a laceration on the client's left arm. Which assessment is most important for the nurse to obtain?

Which client is at greatest risk for aspiration?

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?

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?