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

Answer and Explanation

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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Correct Answer is C

Explanation

A. Place the booster seat where there is an air bag in the vehicle. Booster seats should never be placed in front of an active air bag, especially in the front seat. Air bags can cause serious injury or death to young children in the event of deployment.
B. Avoid using the lap shoulder belt when the child is in a booster seat. A lap-shoulder belt is required for proper use of a booster seat. The shoulder belt helps distribute force across the child’s chest and shoulders in a crash. Using only a lap belt increases the risk of serious abdominal and spinal injuries.
C. Use a no-back booster seat if the vehicle seat has a headrest. This is correct and safe. A no-back booster is appropriate as long as the vehicle seat has a high back or headrest that provides support for the child’s neck and head, ensuring proper positioning of the seat belt.
D. Keep the booster seat rear-facing until the child weighs at least 16 kg (35.3 lb). Booster seats are designed for forward-facing children who have outgrown a forward-facing harness seat, typically around 4 years of age and 40 pounds. Rear-facing seats are used prior to booster seats, for infants and toddlers, not for booster seat-age children.

A. Calories B. Folate C. Calcium D. Protein

Correct Answer is B

Explanation

A. Calories. Significant increases in caloric intake are not necessary during the first trimester. Most women do not require additional calories until the second and third trimesters, when fetal growth accelerates.
B. Folate. Folate (or folic acid) is crucial during early pregnancy, particularly in the first trimester, to prevent neural tube defects such as spina bifida. Women are advised to increase folate intake before conception and during early pregnancy.
C. Calcium. Calcium needs increase later in pregnancy when the fetus's bone development intensifies. While important throughout pregnancy, calcium is not the most critical nutrient to increase specifically in the first trimester.
D. Protein. Protein is essential for fetal growth, but increased protein needs become more important in the second and third trimesters when fetal tissue development peaks. Early pregnancy focuses more on folate supplementation for neural development.

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

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