The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy?
The skin under the appliance looks red briefly after removing the appliance.
The stoma color is a deep red-purple.
An ascending colostomy delivers liquid feces.
The stoma extends 1/2 inch above the abdomen.
The Correct Answer is B
Choice A rationale: Redness briefly after removing the appliance might be common due to increased blood flow but does not necessarily indicate an issue.
Choice B rationale: A deep red-purple stoma color can suggest impaired blood supply to the stoma and requires immediate attention.
Choice C rationale: The consistency of output from the colostomy may vary based on the site and type of colostomy and might not necessarily be concerning.
Choice D rationale: The length of the stoma can vary and usually depends on the type of colostomy, and 1/2 inch above the abdomen is within an acceptable range.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: candidiasis - The described symptoms of inflammation, cottage
cheese-like discharge, and vaginal/vulvar inflammation are indicative of a yeast infection or candidiasis.
Choice B rationale: Chlamydia - Chlamydia often presents with different symptoms such as discharge, but it's not typically associated with a cottage cheese-like appearance.
Choice C rationale: bacterial vaginosis - Bacterial vaginosis typically presents with a different type of discharge, often described as "fishy" smelling, rather than a cottage cheese appearance.
Choice D rationale: trichomoniasis - Symptoms of trichomoniasis usually include frothy, malodorous discharge, not consistent with the described cottage cheese-like discharge.
Correct Answer is C
Explanation
Choice A rationale: Kayexalate is not primarily used for phosphate reduction.
Choice B rationale: Kayexalate can have sorbitol in its formulation, which might cause diarrhea rather than constipation.
Choice C rationale: Kayexalate works as a cation-exchange resin that promotes potassium excretion in the bowels.
Choice D rationale: Kayexalate does not add potassium; it exchanges sodium for potassium in the bowels.
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