A nurse is assessing a client who has a colostomy. Which of the following findings show 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 pale in color.
The Correct Answer is D
A. The skin around the stoma is red: Redness around the stoma may indicate skin irritation, which is common but typically managed with proper skin care and is not always an urgent concern. However, if the redness is severe or associated with other symptoms, it should be monitored. Reporting may be necessary if it worsens.
B. The ostomy is draining frequently: Frequent drainage may be expected depending on the location of the colostomy and the client’s diet. While it should be monitored, frequent drainage alone does not necessarily indicate a problem that needs to be reported.
C. The stool is yellow-green: The color of stool can vary depending on diet, the location of the colostomy, and bile presence. Yellow-green stool is often expected in higher colostomies and may not need to be reported unless it is a sudden change.
D. The stoma is pale in color: A pale or dusky stoma can indicate compromised blood flow, which is a serious concern and should be reported to the provider immediately. A healthy stoma should be pink or red.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Blood glucose levels return to the expected reference range. Blood glucose levels are more likely to be elevated due to prolonged stress during the exhaustion stage, not normalized.
B. Blood pressure increases. During the exhaustion stage, the body's resources are depleted, and blood pressure may drop rather than increase.
C. Depression: The exhaustion stage is characterized by physical and psychological symptoms such as depression, fatigue, and reduced immune function.
D. Dilation of pupils: Pupil dilation occurs during the alarm stage of the general adaptation syndrome, not during the exhaustion stage.
Correct Answer is B
Explanation
A. Moist skin: Dehydration typically causes dry skin due to reduced fluid volume, not moist skin. This finding is not expected in a dehydrated client.
B. Dark-colored urine: Dark-colored urine is a common sign of dehydration, as the urine becomes more concentrated when the body conserves water. This finding is expected.
C. Distended neck veins: Dehydration typically causes flat or collapsed neck veins due to decreased blood volume. Distended neck veins are more associated with fluid overload or heart failure. This finding is not expected.
D. High blood pressure: Dehydration often leads to low blood pressure due to reduced blood volume. High blood pressure is not typically associated with dehydration.
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