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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. Crackles in the lungs: Pulmonary edema causes fluid accumulation in the alveoli, leading to crackles or rales heard during auscultation of the lungs.
B. Jugular vein distension: Increased pressure in the pulmonary circulation can lead to right-sided heart strain, resulting in visible jugular venous distension.
C. Persistent, dry cough: Cough in pulmonary edema is typically productive, often associated with pink, frothy sputum due to fluid leakage into the alveoli.
D. Frothy, blood-tinged sputum: A hallmark sign of pulmonary edema, this occurs as fluid mixed with blood leaks into the alveoli and airways due to high pulmonary capillary pressure.
E. Bradycardia: Pulmonary edema is typically associated with tachycardia as a compensatory response to hypoxia and impaired cardiac output, not bradycardia.
Correct Answer is B
Explanation
A. Insert the oral thermometer in front of the infant's tongue: Oral temperature is not recommended for infants due to the risk of injury and difficulty keeping the thermometer in place.
B. Place the tip of the thermometer under the center of the infant's axilla: The axillary route is safe and appropriate for infants. Ensuring the tip is in full contact with the skin in the center of the axilla ensures a more accurate reading.
C. Pull the pinna of the infant's ear forward before inserting the probe: For infants under 3 years, the pinna should be pulled down and back to straighten the ear canal, not forward.
D. Insert the probe 3.8 cm (1.5 in) into the infant's rectum: This depth is excessive for an infant; rectal insertion should be only about 1.3 to 2.5 cm (0.5 to 1 in) to avoid rectal trauma.
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