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 A
The correct answer is Choice A.
Choice A rationale: A pale blue stoma indicates compromised perfusion or necrosis. This is a surgical emergency requiring immediate assessment to prevent tissue death and systemic complications.
Choice B rationale: Continuous drainage may reflect normal output depending on stoma type. It’s not immediately life-threatening and doesn’t require urgent intervention.
Choice C rationale: Fecal contamination is expected with colostomies. While hygiene is important, this does not indicate a critical issue needing priority care.
Choice D rationale: A beefy red, moist stoma is the expected healthy appearance of a functioning colostomy. No intervention is needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
Choice A: Holding the enema for only 5 minutes may not provide enough time for the mineral oil to soften the stool and facilitate a bowel movement.
Choice B Holding the enema for 60 minutes is unnecessary and can lead to discomfort and difficulty for the patient.
Choice C Holding the enema for only 1 minute is too short for the mineral oil to be effective in softening the stool.
Choice D Encouraging the patient to hold the mineral oil enema for a minimum of 15 minutes allows sufficient time for the oil to work on the stool and improve the chances of a successful bowel movement.
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