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 A

Explanation

A. Orange slices. Vitamin C-rich foods like oranges enhance the absorption of nonheme iron, which is found in plant-based sources such as legumes, leafy greens, and fortified cereals. This is especially important for vegetarians who rely on nonheme iron sources.
B. Boiled eggs. While eggs contain iron, they also contain phosphoproteins that can actually inhibit iron absorption. They do not enhance the absorption of nonheme iron and are not ideal for this purpose.
C. Mixed nuts. Nuts provide a source of nonheme iron but do not significantly enhance iron absorption. They lack vitamin C, which is essential for improving nonheme iron bioavailability.
D. Cheddar cheese. Dairy products like cheese contain calcium, which can inhibit iron absorption. They are not recommended to enhance iron uptake, particularly when consuming nonheme iron.

A. Apply the largest cuff available. B. Deflate the cuff quickly. C. Use the palpatory method to determine blood pressure. D. Place the arm above the level of the client's heart.

Correct Answer is C

Explanation

A. Apply the largest cuff available. Using a cuff that is too large can result in falsely low readings. Cuff size should match the client’s arm circumference to ensure accuracy, but simply switching to the largest cuff does not resolve difficulty in auscultation.
B. Deflate the cuff quickly. Rapid deflation can cause the nurse to miss the systolic and diastolic sounds, making it harder to obtain an accurate reading. The cuff should be deflated at a steady rate of 2–3 mmHg per second.
C. Use the palpatory method to determine blood pressure. When sounds are difficult to auscultate, the palpatory method is a reliable alternative. This involves palpating the radial pulse while inflating the cuff to estimate systolic pressure, which helps guide a more accurate auscultatory attempt.
D. Place the arm above the level of the client's heart. Elevating the arm above heart level can lower the pressure artificially, resulting in an inaccurate measurement. For correct results, the arm should be supported at heart level.

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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?

Nursing Test Bank

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