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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E"]
Explanation
Choice A reason: Fluid and nutrition support overall health but aren’t direct outcomes for peripheral perfusion in artery disease. Warm skin and palpable pulses indicate improved circulation, making this incorrect, as it’s not specific to the nursing diagnosis of ineffective tissue perfusion.
Choice B reason: Adequate urinary output reflects renal perfusion, not peripheral artery disease’s limb perfusion. Palpable pulses are more relevant, making this incorrect, as it does not directly address the peripheral tissue perfusion outcome in the client’s nursing care plan.
Choice C reason: Respiratory distress is unrelated to peripheral artery disease, which affects limb circulation. Warm, dry skin is a perfusion outcome, making this incorrect, as it does not pertain to the nursing diagnosis of ineffective tissue perfusion in the client’s extremities.
Choice D reason: Warm and dry skin indicates improved peripheral perfusion in artery disease, reflecting better blood flow. This aligns with nursing outcomes for tissue perfusion, making it a correct outcome the nurse would expect for the client’s peripheral artery disease management.
Choice E reason: Palpable peripheral pulses demonstrate effective blood flow, a key outcome for peripheral artery disease perfusion. This aligns with vascular nursing goals, making it a correct outcome the nurse would include for the client’s ineffective tissue perfusion diagnosis.
Correct Answer is A
Explanation
Choice A reason: Distended neck veins in the sitting position indicate worsening hypervolemia, reflecting increased venous pressure and heart strain. This aligns with cardiovascular assessment, making it the correct finding the nurse would identify as a sign of deteriorating fluid overload in the client.
Choice B reason: Breath sounds in the right lower lobe are normal unless crackles indicate fluid. Distended neck veins are more specific to worsening hypervolemia, making this incorrect, as it’s not a clear sign of deterioration in the nurse’s fluid status assessment.
Choice C reason: Unchanged weight doesn’t indicate worsening hypervolemia, which causes weight gain. Distended neck veins signal increased fluid, making this incorrect, as it’s not a dynamic finding compared to the nurse’s assessment of worsening fluid overload in the client.
Choice D reason: Yellow-tinged nose and ears suggest jaundice, not hypervolemia. Distended neck veins are a direct sign of worsening fluid status, making this incorrect, as it’s unrelated to the nurse’s evaluation of deteriorating hypervolemia in the client’s condition.
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