A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse?

This is a normal, expected event.

The client is experiencing early signs of ischemic bowel.

The client should not have the nasogastric tube removed.

This indicates inadequate preoperative bowel preparation.

Answer and Explanation

The Correct Answer is A

Choice A reason: Malodorous flatus 2 days post-colostomy is normal, indicating bowel function resumption. This aligns with postoperative colostomy expectations, making it the correct interpretation by the nurse, as flatus is an expected milestone in the client’s recovery process.

Choice B reason: Ischemic bowel causes pain, fever, or absent output, not just malodorous flatus, which is normal post-colostomy. This is incorrect, as it misinterprets a typical finding as a serious complication in the nurse’s assessment of the client’s stoma.

Choice C reason: Flatus doesn’t indicate the need for a nasogastric tube, which is used for obstruction or ileus. Normal flatus is expected, making this incorrect, as it wrongly suggests intervention for a typical post-colostomy finding in the nurse’s evaluation.

Choice D reason: Malodorous flatus is unrelated to preoperative bowel preparation; it’s a normal post-colostomy event. This is incorrect, as it misattributes a standard recovery sign to surgical preparation, unlike the nurse’s correct interpretation of expected bowel function.

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Correct Answer is A

Explanation

Choice A reason: Starting IV fluids is the first action to correct hypotension (72/48) and tachycardia (152) in burn shock, restoring perfusion. This aligns with burn resuscitation protocols, making it the correct action to address the client’s critical hypovolemia and absent pedal pulses immediately.

Choice B reason: Albumin is used later in burn management, not first, as crystalloids like saline restore volume. IV fluids address hypovolemia, making this incorrect, as it’s premature compared to the nurse’s priority of initiating fluid resuscitation in the burn-injured client.

Choice C reason: Checking pulses with Doppler assesses perfusion but delays fluid resuscitation needed for hypotension and shock. IV fluids are urgent, making this incorrect, as it’s secondary to the nurse’s first action of correcting hypovolemia in the burn client’s emergency care.

Choice D reason: Calculating the rule of nines guides fluid volume but is secondary to starting IV fluids for hypotension. Immediate resuscitation is critical, making this incorrect, as it delays the nurse’s priority of addressing the client’s shock state in the burn emergency.

A. The client with suction pressure set at -20 cmH2O. B. The client with bubbling in the drainage tubing. C. The client whose drainage system is standing on the floor. D. The client with continuous bubbling in the drainage chamber.

Correct Answer is D

Explanation

Choice A reason: Suction pressure at -20 cmH2O is standard for chest tubes and not an immediate concern. Continuous bubbling suggests a pneumothorax, making this incorrect, as it’s a normal setting compared to the priority of addressing a potential air leak in the system.

Choice B reason: Bubbling in the drainage tubing is normal with fluid movement, not indicating an issue. Continuous bubbling in the chamber suggests an air leak, making this incorrect, as it’s less urgent than the priority client with a potential pneumothorax requiring immediate assessment.

Choice C reason: A drainage system on the floor risks tipping but is less urgent than continuous bubbling indicating an air leak. The pneumothorax risk takes precedence, making this incorrect, as it’s a secondary issue compared to the priority client’s chest tube complication.

Choice D reason: Continuous bubbling in the drainage chamber suggests an air leak or pneumothorax, a critical complication requiring immediate assessment. This aligns with chest tube management priorities, making it the correct client for the nurse to see first to address a potential emergency.

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A client had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the ED with a burn injury. The client’s vital signs are the following: blood pressure: 72/48, heart rate: 152 beats/min, respiratory rate: 26/min. He is pale in color and the nurse is unable to feel his pedal pulses. Which action will the nurse take first?

Correct Answer is A

Explanation

A nurse has just received report on 4 clients who all have chest tubes in place. Which client is the priority to see first?

Correct Answer is D

Explanation

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