A nurse is assessing a client who had a colostomy 24 hr ago. Which of the following findings is the nurse's priority?

The client reports a pain level of 6 on a scale from 0 to 10

The client refuses to look at the colostomy

The colostomy has had no output

The stoma appears dark purple in color

Answer and Explanation

The Correct Answer is D

Rationale:

A. The client reports a pain level of 6 on a scale from 0 to 10: Moderate pain is expected postoperatively and should be managed, but it does not indicate an immediate threat to tissue viability or life. It is not the top priority when compared to signs of stoma compromise.

B. The client refuses to look at the colostomy: Emotional adjustment is important and should be addressed with sensitivity, but it is a psychosocial concern rather than a physiological emergency. This can be prioritized after physical complications are ruled out.

C. The colostomy has had no output: Absence of output within the first 24 hours may be related to bowel manipulation during surgery. While it should be monitored, it is not as urgent as signs suggesting stoma necrosis or ischemia.

D. The stoma appears dark purple in color: A dark purple stoma indicates poor perfusion or possible necrosis, which is a surgical emergency. A healthy stoma should appear pink or red and moist. Immediate intervention is required to preserve tissue viability.

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Correct Answer is ["A","C","D"]

Explanation

Rationale:

A. "You should eat foods high in protein." Protein is essential for tissue repair and healing, especially after pancreatitis. A diet rich in protein supports recovery and helps maintain muscle mass and immune function.

B. “Limit alcohol intake to no more than one drink per day." Alcohol is a major risk factor for pancreatitis; complete abstinence is necessary to prevent recurrence. Advising to limit intake rather than abstain may lead to misunderstanding and increased risk.

C. "Notify your provider if you experience vomiting or diarrhea." Vomiting and diarrhea may indicate complications such as worsening pancreatitis, infection, or intolerance to diet changes. Early reporting can prevent severe dehydration and further complications.

D. "You should eat foods that are low in fat." Low-fat foods reduce pancreatic stimulation, which is crucial in managing pancreatitis. Consuming high-fat foods can exacerbate symptoms and prolong inflammation.

E. “You can drink beverages that contain caffeine." Caffeine can irritate the gastrointestinal tract and may worsen symptoms in pancreatitis. One should limit or avoid caffeine during recovery.

A. Discuss the client's food preferences with the hospital's dietitian. B. Allow the client's family to bring food from home for the client C. Offer the client's meals on a different schedule. D. Request the provider change the client's prescribed diet

Correct Answer is A

Explanation

Rationale:

A. Discuss the client's food preferences with the hospital's dietitian: Collaborating with the dietitian allows the meal plan to be adjusted based on the client’s cultural, religious, or taste preferences while still meeting dietary requirements. This promotes adherence to the prescribed diet and supports patient-centered care.

B. Allow the client’s family to bring food from home for the client: While family support is valuable, food brought from home may not comply with the ADA diet. This can compromise glucose control unless the food is reviewed and approved by a dietitian.

C. Offer the client’s meals on a different schedule: Changing the meal schedule may not address the client’s refusal to eat if the issue is related to food content rather than timing. Consistency in meal timing is also important in managing blood glucose levels.

D. Request the provider change the client’s prescribed diet: Altering the diet order without first exploring and addressing the client’s preferences or challenges may lead to poor glucose control. The nurse should advocate for personalized modifications rather than a blanket diet change.

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A nurse is assessing a client who had a colostomy 24 hr ago. Which of the following findings is the nurse's priority?

Nursing Test Bank

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Explanation

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Exhibits For each potential assessment finding, click to specify if the finding is consistent with Crohn’s disease, appendicitis or intussusception. Each finding may support more than 1 disease process.