A nurse is assisting with postoperative care of a patient who had surgery for creation of a colostomy 24 hours ago. Which findings should the nurse report to the provider?
The skin around the patient’s stoma is bulging.
The stoma protrudes 2 cm (0.8 in) above the patient’s abdominal wall.
The patient’s stoma is moist and beefy red.
The patient has had no fecal output from the stoma.
The Correct Answer is D
Choice A rationale
Bulging skin around the stoma can be a sign of a hernia, but it’s not uncommon in the early postoperative period. It should be monitored, but it’s not typically a cause for immediate concern.
Choice B rationale
A stoma that protrudes 2 cm (0.8 in) above the abdominal wall is considered normal. The stoma should protrude above the skin to prevent stool from coming into contact with the skin, which can cause irritation and breakdown.
Choice C rationale
A stoma that is moist and beefy red is a sign of a healthy stoma. This indicates that the stoma has a good blood supply and is not ischemic or necrotic.
Choice D rationale
No fecal output from the stoma 24 hours after surgery could indicate a blockage or other complication and should be reported to the provider immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Prick the central tip of the patient’s finger: The central tip of the finger has more nerve endings, making it more painful.Instead, the side of the fingertip should be used because it has fewer nerve endings and promotes better blood flow.
B. Apply the first drop of blood to the test strip: The first drop of blood may contain interstitial fluid or contaminants (e.g., alcohol residue), leading to inaccurate readings.Instead, the first drop should be wiped away, and the second drop should be used for testing.
C. Hold the patient’s finger in a dependent position:Holding the finger in a dependent position (below heart level) helps increase blood flow to the fingertip, making it easier to obtain an adequate blood sample without excessive squeezing, which could dilute the sample with tissue fluid.
D. Clean the patient’s finger with hexachlorophene: Hexachlorophene is not recommended for skin antisepsis before blood glucose testing.Instead, alcohol wipes or soap and water should be used. The finger should be fully dried before pricking to avoid dilution of the blood sample.
Correct Answer is C
Explanation
Choice A rationale
Storing extra blankets in a box on the steps is not a safe practice for a client who has just returned home after a total hip arthroplasty. This could increase the risk of falls, which is a major concern after hip surgery.
Choice B rationale
Keeping pot handles turned towards the edge of the stove is not a safe practice. It increases the risk of spills and burns. Pot handles should always be turned towards the back of the stove to prevent accidents.
Choice C rationale
Placing electrical cords against the wall is a safe practice. It reduces the risk of tripping over the cords, which is especially important for a client who is recovering from a total hip arthroplasty.
Choice D rationale
Placing a throw rug next to the bathtub is not a safe practice. Throw rugs can easily slip and cause falls. A non-slip mat should be used instead.
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