A nurse is assessing a client who has a colostomy and notices that the stoma is pale in color. Which of the following findings should the nurse report to the provider?
The skin around the stoma is red.
The ostomy is draining frequently.
The stool is yellow-green.
The stoma is moist and pink.
The Correct Answer is A
A pale stoma can indicate poor blood flow, which is a serious concern that should be reported to the provider immediately. A healthy stoma should be moist and dark red or pink in color.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["125"]
Explanation
Step 1 is to understand the question. The patient has been prescribed vancomycin 1 g in 250 mL dextrose 5% (D5W) to be administered over 2 hours via IV intermittent bolus. We need to calculate how many mL/hr the nurse should set the IV pump to deliver.
Step 2 is to calculate the rate. The total volume to be administered is 250 mL and the time for administration is 2 hours. So, the rate is 250 mL ÷ 2 hours = 125 mL/hr.
Correct Answer is B
Explanation
Choice A rationale
Troponin is a cardiac enzyme which indicates a client has experienced a myocardial infarction. It is not a laboratory test that supports a diagnosis of malnutrition.
Choice B rationale
Albumin is a measure of plasma proteins which reflects the nutritional condition of a client experiencing anorexia and malnutrition over an extended period of time. Therefore, a nurse
should expect altered albumin levels in a client who reports anorexia and is experiencing malnutrition.
Choice C rationale
Total bilirubin is altered in clients who are experiencing hepatobiliary disease. It is not a laboratory test that supports a diagnosis of malnutrition.
Choice D rationale
Creatine kinase is a cardiac enzyme which is useful in the diagnosis of a myocardial infarction. It is not a laboratory test that supports a diagnosis of malnutrition.
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