A nurse is caring for 4 patients each patient has a colostomy bag. Which patient should be seen first and made a priority?
The patient with a pale blue stoma
The patient with a continuous draining stoma
The patient with a stoma that had fecal contents all over it.
The patient with a beefy red, moist stoma
The Correct Answer is C
Choice A A pale blue stoma may indicate a lack of blood supply (ischemia) to the stoma, which is concerning but not as immediately critical as fecal contamination.
Choice B A continuous draining stoma is normal, and there is no indication of an urgent issue in this scenario.
Choice C This patient should be seen first and made a priority as fecal contamination of the stoma can lead to skin irritation, infection, and complications. Immediate cleaning and appropriate care are necessary.
Choice D A beefy red, moist stoma is a healthy stoma appearance and does not indicate an urgent issue.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale: Waiting until the ostomy drainage bag is full increases the risk of leakage and can put undue pressure on the stoma, leading to potential skin irritation or damage. Regular emptying is crucial for maintaining stoma health and preventing complications.
Choice B rationale: Emptying the ostomy drainage bag when it is 1/2 full is recommended to prevent leaks and reduce pressure on the stoma. This practice helps maintain skin integrity around the stoma and ensures the drainage bag functions effectively.
Choice C rationale: Emptying the ostomy drainage bag when it is only 1/4 full may be too frequent and unnecessary, leading to increased use of supplies and potential irritation from frequent manipulation. It is more practical to aim for 1/2 full for routine care.
Choice D rationale: Waiting until the ostomy drainage bag is 3/4 full increases the risk of leakage and pressure on the stoma, similar to waiting until it is full. It is essential to empty the bag more regularly to maintain optimal stoma health and prevent issues
Correct Answer is B
Explanation
Choice A: KoolAid is not an ideal choice for rehydration as it is high in sugar and may exacerbate diarrhea and dehydration.
Choice B : Gatorade is a suitable option for rehydration because it contains electrolytes (sodium, potassium, and chloride) that help replace those lost through diarrhea. It can help maintain
electrolyte balance and improve hydration.
Choice C Orange juice is not recommended during active diarrhea as it is acidic and may irritate the gastrointestinal tract, potentially worsening diarrhea.
Choice D Cola beverages are not recommended for rehydration as they contain caffeine, sugar, and carbonation, which can further contribute to dehydration.
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