A nurse is assessing a client who had a colostomy 24 hrs ago. Which of the following findings is the nurse's priority?
The stoma appears dark purple in color.
The colostomy has had no output.
The client refuses to look at the colostomy.
The client reports a pain level of 6 on a scale from 0 to 10
The Correct Answer is A
A. The stoma appears dark purple in color. This is a priority finding, as it may indicate impaired circulation or necrosis of the stoma tissue. A healthy stoma should appear pink or red and moist. A dark purple or black color requires immediate evaluation.
B. The colostomy has had no output. While it is important to monitor output, it is not unusual for a new colostomy to have minimal or no output in the first 24–48 hours post-op as bowel function returns.
C. The client refuses to look at the colostomy. This is a psychosocial concern and may indicate body image issues or denial, but it is not the most urgent issue in the immediate postoperative period.
D. The client reports a pain level of 6 on a scale from 0 to 10. Pain management is important, but a pain level of 6, while needing intervention, does not take priority over a potential vascular compromise of the stoma.
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Related Questions
Correct Answer is C
Explanation
A. A client who has a forehead wound that is bleeding copiously. Although bleeding may appear dramatic, most scalp wounds bleed heavily and can be controlled with pressure. This is not immediately life-threatening if the client is stable.
B. A client who has a compound fracture of the femur and is crying in pain. This is a serious injury with risk for blood loss and infection, but the client is alert and stable enough to express pain, suggesting less immediate neurologic risk than other clients.
C. A client who was unconscious at the scene and now reports diplopia and nausea. This client likely has a head injury with signs of increased intracranial pressure or concussion (diplopia = double vision, nausea, and prior loss of consciousness). These are neurological red flags and require immediate evaluation to prevent deterioration.
D. A client who has several missing teeth and a swollen, ecchymotic upper lip. While painful and concerning, oral trauma without airway compromise is less urgent than potential brain injury.
Correct Answer is B
Explanation
A. "Remain on bed rest for 24 hours following the procedure." Prolonged bed rest increases the risk of venous thromboembolism (VTE) and pulmonary complications. Early ambulation or movement is encouraged to promote circulation and prevent complications.
B. "Participate in range-of-motion exercises." Range-of-motion (ROM) exercises help stimulate venous return, improve circulation, and prevent blood stasis, which lowers the risk of postoperative blood clots and muscle stiffness.
C. "Place a pillow under your knees while in bed." Placing a pillow under the knees can impair circulation and increase the risk of venous stasis and thrombus formation. It is not recommended for circulation promotion.
D. "Use an incentive spirometer every 4 hours." While this instruction helps prevent respiratory complications, it is not a direct intervention for improving circulatory function. It's primarily used to promote lung expansion postoperatively.
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