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: This is not relevant to the current condition of the patient and does not support a diagnosis of renal calculi.
Choice B rationale: This is a sign of upper gastrointestinal bleeding, which can have many causes such as peptic ulcer, gastritis or esophageal varices. It is not related to renal calculi or urinary tract problems.
Choice C rationale: Renal calculi usually causes pain which usually radiates anteriorly to the lower abdomen, groin, labia, testicles or the perineum depending on the location of the stone.
Choice D rationale: This is a sign of hematuria, which is blood in the urine caused by the passage of renal calculi (kidney stones) through the urinary tract. Hematuria can also cause the urine to appear dark or brown in color.
Correct Answer is D
Explanation
Choice A rationale: This is not the accurate amount of fluid intake by the patient.
Choice B rationale: This is less than the total fluid intake by the patient.
Choice C rationale: This is less than the total fluid intake by the patient.
Choice D rationale: This is correct.( This is the sum of the intravenous fluid, the water, and the chicken broth, converted to milliliters: 650 + (6 x 30) + (8 x 30) = 1070.)
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