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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While an antiemetic might help with the vomiting, it would not address the underlying issue of not having a bowel movement for 4 days. Therefore, this choice is incorrect.
Choice B rationale
If the client has a nasogastric tube, checking its position would be a good first step. If the tube is not in the correct position, it could be causing or contributing to the client’s symptoms.
Therefore, this choice is correct.
Choice C rationale
Increasing the suction on a nasogastric tube might help if the tube is functioning correctly and the problem is related to stomach contents not being properly evacuated. However, it would not be the first step before checking the position of the tube. Therefore, this choice is incorrect.
Choice D rationale
Repositioning the nasogastric tube might be necessary if it’s not in the correct position, but this would not be the first step before checking its position. Therefore, this choice is incorrect.
Correct Answer is C
Explanation
Choice C rationale
Placing the client in Fowler's position (semi-upright position) facilitates optimal chest expansion and improves ventilation by allowing the diaphragm to move more effectively and reducing the pressure on the lungs from abdominal contents. This position helps in maximizing oxygenation and reducing respiratory distress. The other positions—supine, prone, and Trendelenburg—do not offer the same level of chest expansion and can exacerbate breathing difficulties.
The correct answer is to place the client in a position that allows for maximum chest expansion and oxygenation. This is often the upright or Fowler’s position.
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