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 D
Explanation
Choice A rationale: Symptoms and findings described align more with an acute, severe condition rather than a chronic one.
Choice B rationale: While cholecystitis can present with similar symptoms, the radiation of pain to the back is more indicative of a different condition.
Choice C rationale: Cholelithiasis (gallstones) might cause abdominal pain but typically doesn’t lead to fever and hypotension.
Choice D rationale: Symptoms including severe abdominal pain, radiation to the back, fever, and hypotension suggest acute pancreatitis, a potentially serious condition requiring urgent medical attention.
Correct Answer is C
Explanation
Choice A rationale: This symptom typically indicates secondary syphilis, not gonorrhea.
Choice B rationale: Warts on the genitals suggest a different sexually transmitted infection caused by HPV, not gonorrhea.
Choice C rationale: A discharge from the penis is a common symptom of gonorrhea and often prompts individuals to seek medical attention.
Choice D rationale: While discomfort can be associated with gonorrhea, the primary presenting symptom often involves discharge rather than specific lesions.
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