The nurse is providing care for a client with a recent transverse colostomy. Which observation requires immediate notification of the primary health care provider?
Soft pasty stool is noted in the collection device
There is purple discoloration of the stoma
Stoma is beefy red
There is skin excoriation around the stoma
The Correct Answer is B
Choice A Reason: Soft pasty stool is normal for a transverse colostomy, as the stool has not reached the sigmoid colon where most of the water is absorbed.
Choice B Reason: This is the correct answer because purple discoloration of the stoma indicates ischemia or necrosis, which can lead to infection, perforation, or sepsis. It requires urgent intervention.
Choice C Reason: Stoma is beefy red is a normal finding for a healthy stoma, as it indicates adequate blood supply and healing.
Choice D Reason: There is skin excoriation around the stoma is a common complication of a colostomy, as the stool can irritate the skin. It can be managed with proper skin care and appliance fitting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: Culture is not a diagnostic test that uses an ultraviolet light source, but a laboratory test that involves growing microorganisms from a sample of body fluid or tissue. Culture can help identify the type and sensitivity of the infection-causing agent.
Choice B Reason: KOH is not a diagnostic test that uses an ultraviolet light source, but a chemical test that involves applying potassium hydroxide to a sample of skin, hair, or nail. KOH can help diagnose fungal infections by dissolving the keratin and revealing the fungal elements under a microscope.
Choice C Reason: Diascopy is not a diagnostic test that uses an ultraviolet light source, but a physical test that involves applying pressure to a lesion with a glass slide or lens. Diascopy can help differentiate between blanchable and non-blanchable lesions, such as erythema or petechiae.
Choice D Reason: Wood's is a diagnostic test that uses an ultraviolet light source, also known as a Wood's lamp or black light. Wood's can help observe color changes to the skin that are not visible under normal light, such as fluorescence or hypopigmentation. Wood's can help diagnose conditions such as tinea capitis, vitiligo, or erythrasma.
Correct Answer is C
Explanation
Choice A Reason: Reporting itching if it becomes bothersome is part of client teaching, as it may indicate inflammation or infection of the ear canal. External otitis is also known as swimmer's ear, as it can be caused by water trapped in the ear after swimming or bathing.
Choice B Reason: Using earplugs when swimming is part of client teaching, as it can prevent water from entering and irritating the ear canal. External otitis can be prevented by keeping the ear dry and avoiding trauma or foreign objects.
Choice C Reason: This is the correct choice. Inserting a cotton-tip applicator to remove excess wax is not part of client teaching, as it can damage or scratch the ear canal and increase the risk of infection. Wax helps protect and lubricate the ear canal and should not be removed unless it causes hearing impairment or discomfort.
Choice D Reason: Using a hairdryer set to low, 6 inches away from ear is part of client teaching, as it can help dry the ear canal after swimming or bathing. External otitis can be treated by applying warm compresses, using topical antibiotics or antifungals, and taking pain relievers or anti-inflammatory drugs.
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