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 D
Explanation
Choice A rationale
Experiencing incontinence whenever taking a diuretic may suggest a type of functional incontinence, where the incontinence is linked to the inability to reach a restroom due to the sudden urge to urinate caused by the diuretic23.
Choice B rationale
Leaking urine when sneezing is typically a symptom of stress incontinence, which occurs when pressure is placed on the bladder during physical movement or activity23.
Choice C rationale
A bladder that seems to empty without warning may suggest urge incontinence, which is characterized by a sudden, intense urge to urinate followed by an involuntary loss of urine23.
Choice D rationale
Frequently experiencing dribbling of urine is a common symptom of overflow incontinence, which occurs when the bladder doesn’t empty properly, leading to frequent or constant dribbling23.
Correct Answer is C
Explanation
Choice A rationale
Keeping unopened insulin vials in the freezer is not recommended. Freezing can disrupt the insulin molecule and affect its efficacy.
Choice B rationale
Planning to eat a snack 6 hours after insulin administration is not a standard recommendation. The timing of meals and snacks should be individualized based on the type of insulin, blood glucose levels, and lifestyle.
Choice C rationale
Storing opened insulin vials at room temperature for up to 4 weeks is a correct practice. Insulin stored at room temperature causes less discomfort on injection than cold insulin.
Choice D rationale
Warming the insulin vial to dissolve any crystals that develop is not a standard practice. Insulin should not be used if it appears cloudy or discolored.
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