The nurse assesses an adult client 24 hours after a bowel exploration and formation of a sigmoid colostomy. Which assessment finding should be reported to the surgeon immediately?

The stoma has streaks of bright red blood.

There are no bowel sounds in the left lower quadrant.

The fecal matter is brown and has a solid consistency.

The stoma mucosa is purple in color.

Answer and Explanation

The Correct Answer is D

Choice A reason: While streaks of bright red blood in the stoma can be concerning, it is not necessarily an immediate emergency. It may indicate minor trauma or irritation, but it does not require immediate surgical intervention unless accompanied by other symptoms.

Choice B reason: The absence of bowel sounds in the left lower quadrant can indicate a lack of intestinal activity, which may be a concern, but it is not an immediate surgical emergency. It requires monitoring and further assessment.

Choice C reason: Brown, solid fecal matter is a normal finding and indicates that the colostomy is functioning properly. This is not a cause for immediate concern.

Choice D reason: The stoma mucosa being purple in color is a critical finding that requires immediate reporting to the surgeon. Purple stoma mucosa can indicate compromised blood flow or ischemia, which can lead to tissue necrosis and serious complications if not addressed promptly.

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Correct Answer is A

Explanation

Choice A reason: Continuous cardiac monitoring is crucial for a client who has suffered an electrical injury. Electrical injuries can cause arrhythmias and other cardiac complications, which may not be immediately apparent. Continuous monitoring allows for the early detection and treatment of any cardiac abnormalities, which is vital for the patient's safety and recovery.

Choice B reason: Evaluating the level of consciousness is important for any patient, especially those with significant injuries, but it is not the most critical intervention in this scenario. While neurological assessments are part of comprehensive care, the immediate risk posed by cardiac complications from the electrical injury takes precedence.

Choice C reason: Performing passive range of motion exercises is beneficial for preventing contractures and maintaining joint mobility in immobile patients. However, it is not the most urgent intervention in the context of an electrical injury, where cardiac monitoring is paramount.

Choice D reason: Assessing lung sounds every 4 hours is a valuable part of monitoring for respiratory complications, particularly in burn patients. However, the immediate cardiac risks associated with electrical injuries necessitate continuous cardiac monitoring as the priority intervention.

A. Place chin down and tilt head for dyspahgia during meals. B. Normal saline mouth rinses as swish and spit after meals and bedtime. C. Eat high caloric meals to prevent weight loss. D. Use a commercial mouthwash for xerostomia.

Correct Answer is B

Explanation

Choice A reason: Placing the chin down and tilting the head for dysphagia (difficulty swallowing) during meals is not directly related to managing mucositis. While it may help with swallowing difficulties, it does not address the inflammation and pain caused by mucositis.

Choice B reason: Normal saline mouth rinses as swish and spit after meals and bedtime is an effective intervention for managing mucositis. Rinsing with saline helps to keep the mouth clean, reduce bacterial load, and soothe inflamed tissues. It can also help to remove food particles and debris, reducing the risk of infection and promoting healing. Saline rinses are gentle and do not contain irritating ingredients, making them ideal for sensitive oral tissues affected by mucositis.

Choice C reason: Eating high caloric meals to prevent weight loss is important for overall nutrition, especially for clients undergoing cancer treatment. However, it does not specifically address the management of mucositis. High caloric meals alone will not alleviate the pain, inflammation, and ulceration associated with mucositis. Clients with mucositis often have difficulty eating due to pain, so focusing on soothing and healing the oral tissues is a priority before addressing caloric intake.

Choice D reason: Using a commercial mouthwash for xerostomia (dry mouth) is not recommended for managing mucositis. Many commercial mouthwashes contain alcohol and other harsh ingredients that can further irritate the already inflamed mucous membranes. It is better to use a gentle and soothing rinse, such as saline, to manage mucositis symptoms and promote healing of the oral tissues.

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The nurse assesses an adult client 24 hours after a bowel exploration and formation of a sigmoid colostomy. Which assessment finding should be reported to the surgeon immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is B

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