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 A
Explanation
Choice A rationale
Sudden jaw pain can be a symptom of a heart attack. It’s important to seek immediate medical attention if this occurs.
Choice B rationale
While some people may experience hot, dry, and flushed skin during a heart attack, it’s not a common symptom and should not be relied upon as an indicator.
Choice C rationale
Waiting 30 minutes before taking action if experiencing heartburn is not advisable, especially if the individual has a history of heart disease. Heartburn can sometimes be a symptom of a heart attack.
Choice D rationale
Nitroglycerin is typically taken at the first sign of chest pain. If the pain does not improve or worsens after one dose, it’s important to seek immediate medical attention.
Correct Answer is A
Explanation
Choice A rationale
If 500 mL of fluid is removed during thoracentesis, the nurse should notify the provider. Removing large volumes of fluid can cause re-expansion pulmonary edema.
Choice B rationale
A clear chest x-ray is an expected finding after thoracentesis.
Choice C rationale
PCO2 is a measure of carbon dioxide levels in the blood. It is not directly related to thoracentesis.
Choice D rationale
Hematocrit is a measure of the proportion of red blood cells in the blood. It is not directly related to thoracentesis.
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