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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale

Increased collagen is not a factor that would lead to a pressure injury in a client with impaired mobility. Collagen is a protein that helps in the formation of skin and other connective tissues.

Choice B rationale

Decreased serum calcium is not directly related to the development of pressure injuries. While calcium is important for bone health and muscle function, it does not play a direct role in skin integrity.

Choice C rationale

Increased muscle mass is not a risk factor for pressure injuries. In fact, good muscle mass can help distribute pressure more evenly and potentially reduce the risk of pressure injuries.

Choice D rationale

Decreased circulation is a major risk factor for the development of pressure injuries. When blood flow to an area of the body is reduced, the tissues in that area can become deprived of oxygen and nutrients, leading to cell death and the formation of pressure injuries.

A. Use soap to clean the patient’s skin. B. Apply a barrier cream to the patient’s skin. C. Avoid applying friction when drying the patient’s skin. D. Use warm water to clean the patient’s skin.

Correct Answer is ["B","C","D"]

Explanation

Choice A rationale

Using soap to clean the patient’s skin is not the best practice. Soap can dry out and irritate the skin, especially in patients with urinary incontinence. It can disrupt the skin’s natural pH balance and make it more susceptible to damage.

Choice B rationale

Applying a barrier cream to the patient’s skin is a recommended practice. Barrier creams provide a protective layer on the skin that can help prevent irritation from urine. They can also help to keep the skin moisturized, which is important for maintaining skin integrity.

Choice C rationale

Avoiding friction when drying the patient’s skin is crucial. Friction can cause further damage to the skin, especially in areas that are already irritated or broken down due to incontinence. It’s recommended to gently pat the skin dry rather than rubbing it.

Choice D rationale

Using warm water to clean the patient’s skin is a good practice. Warm water is less irritating to the skin than hot water and can help to cleanse the area without causing additional discomfort or damage.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has impaired mobility.The nurse should monitor the client for a pressure injury due to which of the following factors?

Correct Answer is D

Explanation

A nurse is providing skin care for a patient with urinary incontinence. What actions should the nurse take?

Correct Answer is ["B","C","D"]

Explanation

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