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. Speech therapist B. Occupational therapist C. Physical therapist D. Recreational therapist

Correct Answer is B

Explanation

A. Speech therapist: A speech therapist is typically involved in addressing communication and swallowing difficulties, not difficulties with using utensils.
B. Occupational therapist: This is correct as an occupational therapist specializes in helping clients with daily living activities, including fine motor skills and adaptive techniques for using utensils.
C. Physical therapist: Physical therapists focus on improving mobility, strength, and coordination but do not primarily address difficulties with using utensils.
D. Recreational therapist: Recreational therapists focus on leisure activities and hobbies, which are not directly related to the use of utensils for eating.

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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

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has hypernatremia. Which of the following interventions should the nurse recommend to include in the plan?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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