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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale: The 42-yr-old patient with secondary amenorrhea may have menopause, pregnancy, or a hormonal disorder. This is less urgent compared to the 19- year old patient.

Choice B rationale: This patient may have toxic shock syndrome, which is a life- threatening complication of tampon use that can cause organ failure and shock. The nurse should assess the patient's vital signs, remove the tampon, and initiate fluid resuscitation and antibiotic therapy.

Choice C rationale: This patient may have an infection or a complication of the balloon thermotherapy, which is a procedure to destroy the endometrial lining of the uterus and is not an emergency compared to the 19 year old.

Choice D rationale: This patient may have a displacement or perforation of the IUD, which is a contraceptive device that releases progestin into the uterus. However, this is not urgent compared to the 19 year old.

A. A 58-year-old client with gastrointestinal reflux disease B. A 65-year-old client with mild emphysema C. A 72-year-old client with hyperthyroidism D. A 48-year-old client with hypertension

Correct Answer is D

Explanation

Choice A rationale: Gastrointestinal reflux disease is not typically a contraindication for sumatriptan.

Choice B rationale: Mild emphysema is not typically a contraindication for sumatriptan.

Choice C rationale: Hyperthyroidism is not typically a contraindication for sumatriptan.

Choice D rationale: Sumatriptan, a medication used for migraines, may elevate blood pressure, so it would be questionable for a client with hypertension.

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The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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