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 B

Explanation

A. Perform the Credé’s maneuver. This technique, involving manual pressure on the bladder, is used to promote urination in clients with bladder retention. It is not appropriate for a client with a catheter and continuous bladder irrigation in place.
B. Maintain the irrigation solution rate. Pink-tinged urine is an expected finding 4 hours after a TURP as minor bleeding can occur. There is no need to adjust the irrigation rate unless clots form or the urine becomes bright red or obstructed.
C. Warm the irrigation solution. Warming the solution is not a standard intervention and does not directly manage postoperative bleeding or pink urine. Room temperature solution is typically used unless otherwise specified by the provider.
D. Replace the indwelling urinary catheter. There is no indication the catheter is malfunctioning or obstructed. Pink urine alone does not warrant replacement, and unnecessary catheter changes can increase infection risk.

A. Platelet count B. OPIT C. Fibrinogen level D. INR

Correct Answer is D

Explanation

A. Platelet count. While important for evaluating bleeding risk, platelet count is not directly used to adjust or determine daily warfarin dosing. Warfarin affects the coagulation cascade, not platelet function.
B. aPTT. The activated partial thromboplastin time (aPTT) is used to monitor heparin therapy, not warfarin. It assesses the intrinsic pathway of coagulation and is not sensitive to warfarin’s effects on the clotting factors.
C. Fibrinogen level. Fibrinogen is involved in clot formation, but its measurement is not part of routine warfarin management. It is more relevant in evaluating bleeding disorders or disseminated intravascular coagulation (DIC).
D. INR. The international normalized ratio (INR) is the primary lab value used to monitor the effectiveness and safety of warfarin therapy. It helps guide daily dosing by reflecting how long it takes blood to clot, with therapeutic ranges typically between 2.0 and 3.0 for most conditions.

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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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