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
Choice A rationale
A physical therapist focuses on improving a client’s movement, mobility, and function, and relieving pain. They may not specialize in helping clients with difficulties using utensils during meals.
Choice B rationale
A recreational therapist uses a variety of modalities, including arts and crafts, animals, sports, games, dance and movement, drama, music, and community outings to help maintain or improve a patient’s physical, social, and emotional well-being. However, they may not be the best fit for a client having difficulty using utensils during meals.
Choice C rationale
An occupational therapist specializes in helping people regain, develop, and build skills that are important for independent functioning, health, and well-being. They can provide strategies and make recommendations for adaptive equipment, such as specially designed utensils, to
help the client with Parkinson’s disease eat more independently. Therefore, referring the client to an occupational therapist would be the most beneficial.
Choice D rationale
A speech therapist specializes in the evaluation and treatment of communication disorders and swallowing disorders. While they could assist if the client had difficulties with swallowing, they may not be the best fit for a client having difficulty using utensils during meals.
Correct Answer is C
Explanation
Choice A rationale
Loosening the screws while cleaning the pin sites is not recommended. The screws are tightened to a specific pressure to ensure the halo vest is secure and provides the necessary immobilization.
Choice B rationale
The nurse should also provide education regarding changing positions at least every 2 hours to reduce pressure injuries.
Choice C rationale
Halo-vests are managed and monitored during spinal outpatient clinics and can be removed during this clinic appointment.
Choice D rationale
The halo ring should never be used to lift or reposition the client because it is directly attached to the skull. Pulling on the ring could cause serious injury or dislocation.
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