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 O to 10.
The client refuses to look at the colostomy.
The colostomy has had no output.
The Stoma appears dark purple in color.
The Correct Answer is D
A. The client reports a pain level of 6 on a scale from 0 to 10: Moderate pain is expected after surgery and should be managed, but it is not immediately life-threatening or the highest priority.
B. The client refuses to look at the colostomy: Emotional adjustment is important, but this does not pose an immediate physical risk to the client and can be addressed over time with support and education.
C. The colostomy has had no output: It is common for a new colostomy to have delayed output within the first 24 hours postoperatively, so this finding is expected and not immediately concerning.
D. The stoma appears dark purple in color: A dark purple stoma indicates compromised blood flow or ischemia, which is a medical emergency requiring immediate intervention to prevent tissue necrosis and further complications.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Client was nauseated immediately after surgery: While postoperative nausea is important to document, it is an event that occurred in the past and may not reflect the client’s current status 36 hours after surgery.
B. Client’s pain relieved by position change: This information is critical as it reflects the current effectiveness of nonpharmacologic pain management strategies and guides ongoing care for comfort.
C. Checked for peripheral IV blood return prior to antibiotic: This is a routine nursing task that was completed. While important for safe medication administration, it's a procedural detail of a completed task and not usually included in a concise shift report.
D. Client provided with breakfast tray at 0800: Although documenting nutrition is important, the exact timing of meal delivery is less significant than clinical status information during shift handoff.
Correct Answer is C
Explanation
A. Apply splints to the child's extremities during the day: Splints are typically used at night to support proper joint positioning and reduce stiffness during rest. Using them during the day may limit the child’s mobility and interfere with normal activity, which is not ideal for joint health.
B. Keep the child on bedrest as long as pain persists: Prolonged bedrest can lead to increased joint stiffness and muscle wasting. Maintaining activity within comfort levels is encouraged to promote mobility and joint flexibility.
C. Have the child take a tub bath each morning: Warm tub baths in the morning help to relieve joint stiffness, improve circulation, and make it easier for the child to move comfortably throughout the day. This non-pharmacologic intervention supports daily function.
D. Encourage the child to take naps during the day: While adequate rest is important, excessive daytime napping may reduce physical activity, which is necessary to maintain joint function and overall well-being in juvenile idiopathic arthritis.
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