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 A
Explanation
Choice A Reason: This is incorrect because Ménière's disease is not caused by an allergic response. Ménière's disease is a disorder of the inner ear that causes vertigo, tinnitus, hearing loss, and a feeling of fullness in the ear. The exact cause of Ménière's disease is unknown, but it may be related to fluid imbalance, infection, trauma, or autoimmune reaction.
Choice B Reason: This is correct because diphenhydramine can help offset the nauseous feeling. Diphenhydramine is an antihistamine that blocks histamine receptors in the brain and inner ear, which can reduce nausea and vomiting associated with vertigo.
Choice C Reason: This is correct because anticholinergics will help you rest. Anticholinergics are a class of drugs that block acetylcholine receptors in the brain and body, which can have sedative effects and reduce motion sickness. Diphenhydramine has anticholinergic properties.
Choice D Reason: This is correct because diphenhydramine can help reduce vomiting episodes. As mentioned above, diphenhydramine can reduce nausea and vomiting by blocking histamine receptors in the brain and inner ear.
Correct Answer is C
Explanation
Choice A Reason: Educating the client about the therapy is an important action by the nurse, but not the priority one. The nurse should explain the purpose, procedure, benefits, and risks of hydrotherapy to the client before starting it, but only after ensuring their comfort and pain relief.
Choice B Reason: Providing analgesics after therapy ends is not enough, as the nurse should provide them before and during therapy as well. Hydrotherapy involves cleansing and debriding of burn wounds with water jets or whirlpools, which can be very painful and stressful for the client.
Choice C Reason: This is the correct choice. Providing analgesics before therapy begins is the priority action by the nurse, as it reduces pain and anxiety for the client and facilitates wound healing. The nurse should assess the client's pain level and administer appropriate analgesics at least 30 minutes before hydrotherapy.
Choice D Reason: Ensuring there are clean supplies is an essential action by the nurse, but not the priority one. The nurse should use sterile or clean equipment and solutions for hydrotherapy to prevent infection and contamination of burn wounds, but only after ensuring their comfort and pain relief.
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