A nurse is assisting with postoperative care of a client who had surgery for creation of a colostomy 24 hr ago. Which of the following findings should the nurse report to the provider?

The skin around the client's stoma is bulging.

The client has had no fecal output from the stoma.

The stoma protrudes 2 cm (0.8 in) above client's abdominal wall.

The client's stoma is moist and beefy red.

Answer and Explanation

The Correct Answer is B

A. The skin around the client's stoma is bulging: While bulging skin can be concerning, it is often a normal postoperative finding as the stoma settles into its new position. However, further evaluation may be needed if other symptoms are present.
B. The client has had no fecal output from the stoma: This is correct as the absence of fecal output 24 hours postoperatively could indicate a potential issue such as a blockage or anastomotic failure, which requires prompt evaluation by the provider.
C. The stoma protrudes 2 cm (0.8 in) above client's abdominal wall: This is generally considered normal. The stoma should protrude slightly to ensure it is not retracted and is functioning properly.
D. The client's stoma is moist and beefy red: This is a normal finding. A healthy stoma should be moist and beefy red, indicating good blood flow and viability.

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Correct Answer is B

Explanation

A. Restrict fluid intake: This would not be appropriate for hypernatremia, as fluid intake should generally be increased to help dilute serum sodium levels.
B. Restrict sodium intake: This is correct as reducing sodium intake helps manage hypernatremia by decreasing the amount of sodium in the bloodstream.
C. Administer a potassium supplement: Potassium supplementation is not indicated for hypernatremia and could lead to imbalances.
D. Administer a laxative: A laxative is not relevant for managing hypernatremia and does not address the underlying issue of high sodium levels.

A. "I should take my supplement with an antacid to prevent an upset stomach." B. "I should increase my fiber intake while taking this supplement." C. "I should drink my liquid iron supplement undiluted." D. "I should notify my doctor if my stools turn black."

Correct Answer is B

Explanation

A. "I should take my supplement with an antacid to prevent an upset stomach": This is incorrect as antacids can interfere with the absorption of iron. Iron supplements should be taken on an empty stomach for better absorption.
B. "I should increase my fiber intake while taking this supplement": This is correct as increasing fiber can help manage constipation, a common side effect of iron supplementation.
C. "I should drink my liquid iron supplement undiluted": This is incorrect. Liquid iron supplements should be diluted to prevent staining of teeth and to improve tolerance.
D. "I should notify my doctor if my stools turn black": This is incorrect because black stools are a common side effect of iron supplementation and are generally not a cause for concern.

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A nurse is assisting with postoperative care of a client who had surgery for creation of a colostomy 24 hr ago. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

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