The nurse is assessing a client who is 24-hours post-op after creation of a descending end colostomy due to colon cancer. Which of the following is an expected finding for this client?
The stoma will be edematous in appearance.
Bowel sounds will be hyperactive.
The colostomy appliance will need to be replaced
The colostomy will be producing fecal matter from the proximal stoma and mucus from the distal stoma.
The Correct Answer is A
A. The stoma will be edematous in appearance; this is an expected finding 24 hours after surgery. Mild to moderate edema is normal due to surgical manipulation and should gradually decrease over time.
B. Bowel sounds are often hypoactive or absent immediately post-op due to anesthesia and bowel manipulation, not hyperactive.
C. The colostomy appliance typically remains in place unless there's a leak or issue; routine replacement is not expected at 24 hours post-op.
D. A descending end colostomy involves only one stoma from the proximal end of the bowel; there is no distal stoma, so this option does not apply.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While monitoring for dysrhythmias is important for certain cardiovascular conditions, it is not the primary concern for an AAA. The management of blood pressure and preventing rupture are higher priorities.
B. While blood clots can be a concern in some cardiovascular conditions, thrombus formation is not a primary concern with AAA management unless other risk factors (such as venous stasis or atrial fibrillation) are present.
C. Monitoring for bleeding would be more relevant if the aneurysm were large or there were signs of rupture, but for a small AAA, the primary concern is managing blood pressure and preventing further enlargement. Bleeding monitoring is more critical in cases of rupture or larger aneurysms.
D. Antihypertensive medications are crucial for controlling blood pressure and preventing further stress on the aneurysm. Adherence to these medications is essential in managing the condition medically to reduce the risk of rupture or further enlargement of the aneurysm.
Correct Answer is A
Explanation
A. Jugular vein distention and +3 peripheral edema are signs of right-sided heart failure, which can result from worsening mitral stenosis. As the mitral valve becomes more narrowed, it leads to increased pressure in the left atrium and eventually backs up into the lungs and right side of the heart, causing fluid retention.
B. An increase in systolic blood pressure by 10 mmHg does not directly indicate worsening mitral stenosis. Blood pressure changes can occur for various reasons but are not as specific as signs of heart failure in this context.
C. Complaints of epigastric pain after eating a large meal are typically related to gastrointestinal issues rather than directly indicating worsening mitral stenosis.
D. Complaints of dyspnea while completing activities of daily living (ADLs) can be a sign of worsening mitral stenosis, but the additional signs of jugular vein distention and edema are more definitive indicators of worsening disease.
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