A nurse is assessing a client's stoma on postoperative day 2. The nurse notes that the stoma has a shiny appearance and a bright red color. How should the nurse respond?
Document a nursing diagnosis of Impaired Skin Integrity.
Document that the stoma appears healthy and well perfused.
Contact the primary care provider to report this finding.
Irrigate the ostomy to clear a possible obstruction.
The Correct Answer is B
Choice A reason: Impaired skin integrity typically refers to the breakdown of the peristomal skin, not the stoma itself. A shiny, bright red stoma indicates healthy mucosal tissue with an intact blood supply. Assessing the surrounding skin for redness or excoriation is important, but the stoma description provided is normal.
Choice B reason: Following a colostomy or ileostomy, a healthy stoma should appear moist, shiny, and reddish-pink to bright red, similar to the mucous membranes of the mouth. This appearance confirms adequate vascular perfusion to the intestinal segment. The nurse should document these findings as normal postoperative clinical observations.
Choice C reason: There is no clinical indication to notify the provider in this scenario. Providers should be contacted if the stoma appears pale, dusky, purple, or black, as these colors suggest ischemia or necrosis. Since a bright red color is the gold standard for stoma health, reporting it would be unnecessary.
Choice D reason: Irrigation is a procedure used for specific types of colostomies to regulate bowel movements or clear blockages. It is never performed based solely on the color of a stoma and is generally contraindicated in the immediate postoperative period before the bowel has had sufficient time to heal.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Standard maintenance hemodialysis is typically not performed daily in a clinical setting. While some home hemodialysis programs offer more frequent, shorter sessions, the conventional schedule for the vast majority of patients in outpatient centers involves three sessions per week. Daily dialysis is usually reserved for acute, unstable patients in intensive care units.
Choice B reason: The description of a catheter inserted into the abdomen refers to peritoneal dialysis, not hemodialysis. Hemodialysis requires vascular access, such as an arteriovenous fistula, graft, or a central venous catheter in the chest or neck. Peritoneal dialysis uses the peritoneal membrane as the filter, whereas hemodialysis uses an external artificial kidney machine.
Choice C reason: In the United States and most clinical protocols, the standard frequency for outpatient hemodialysis is three times per week, with each session lasting approximately 3 to 5 hours. This schedule is designed to sufficiently remove metabolic waste products and excess fluid that accumulate when the kidneys have reached end-stage failure.
Choice D reason: End-stage renal disease (ESRD) is characterized by permanent, irreversible kidney damage. Unlike acute kidney injury, where the kidneys may eventually heal and resume function, ESRD requires lifelong renal replacement therapy (dialysis) or a kidney transplant. Teaching the client that the kidneys will "heal" provides false hope and inaccurate medical information.
Correct Answer is A
Explanation
Choice A reason: The client's hemoglobin of 8.9 g/dL and hematocrit of 27% represent significant anemia. Combined with "darker" stools (suggestive of melena) and a history of colorectal cancer, these clinical manifestations strongly indicate chronic occult blood loss from a gastrointestinal malignancy, leading to iron-deficiency anemia and subsequent systemic hypoxia symptoms.
Choice B reason: Dehydration typically causes hemoconcentration, which results in elevated hemoglobin and hematocrit levels rather than the decreased values seen here. While dehydration can cause dizziness and fatigue, it does not explain the dark stools or the specific microcytic-type anemia clinical picture presented in this oncology context.
Choice C reason: Acute intestinal obstruction usually presents with severe abdominal pain, vomiting, obstipation, and abdominal distension. While a tumor can cause an obstruction, the primary symptoms reported here (fatigue, dizziness, and low blood counts) are classic indicators of chronic blood loss and anemia rather than an acute mechanical blockage.
Choice D reason: Attributing significant anemia and melena to normal aging is a diagnostic error. While fatigue can occur with age, a hemoglobin level of 8.9 g/dL is always pathological. Nurses must recognize these as "red flag" symptoms requiring urgent investigation for recurrence of malignancy or other serious physiological disturbances.
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