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 C

Explanation

Rationale:

A. Tinnitus: Tinnitus is not a known or common adverse effect of clozapine. While it may indicate another condition, it does not require immediate reporting in the context of clozapine therapy.

B. Dizziness: Dizziness can occur due to clozapine’s hypotensive effects, especially when initiating therapy. It is usually self-limiting and managed symptomatically unless it worsens or affects safety.

C. Sore throat: A sore throat can signal the onset of agranulocytosis, a life-threatening side effect of clozapine marked by a dangerously low white blood cell count. It must be reported immediately for prompt blood count evaluation.

D. Diaphoresis: Diaphoresis may occur with many medications and is not specific to clozapine toxicity or serious adverse effects. It typically does not warrant immediate reporting unless severe or part of a broader concerning symptom complex.

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"C"}

Explanation

Rationale for Correct Choices:

Intravenous antibiotic: The client shows multiple signs of endometritis: uterine tenderness, foul-smelling lochia, fever, tachycardia, and elevated WBC count. IV antibiotics are the first-line treatment for postpartum uterine infections, particularly after cesarean delivery with risk factors like prolonged rupture of membranes.
Increase in daily fluid intake: Clients with infection and fever require increased hydration to support perfusion, manage elevated metabolic demands, and help clear the infection. Fever and poor bowel motility may also contribute to mild dehydration, making fluid support essential.

Rationale for Incorrect Choices:

Intrauterine tamponade balloon: This is used to control postpartum hemorrhage due to uterine atony or trauma. Although the fundus was boggy, it firmed with massage, and there is no indication of active or excessive bleeding, making tamponade unnecessary.
Kleihauer-Betke test: This test detects fetal blood in the maternal circulation and is used after trauma or suspected fetal-maternal hemorrhage, especially in Rh-negative mothers. It is not relevant to this postpartum infection scenario.
Tocolytic medication: Tocolytics are used during pregnancy to suppress preterm labor by relaxing the uterus. In the postpartum period, they are not indicated and would be contraindicated in the presence of infection, as they can reduce uterine tone and worsen involution.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is taking clozapine. Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

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Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"C"}

Explanation

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