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 C
No explanation
Correct Answer is A
Explanation
Choice A Addressing the cause of the patient's anxiety and fear is the priority to provide
emotional support and comfort. The nurse should actively listen to the patient's concerns and offer appropriate reassurance and information.
Choice B While assessing the patient's bowel sounds and gas is important for the overall care, it is not the priority at this moment when the patient is expressing fear and anxiety.
Choice C Addressing the family's questions is important, but the patient's emotional wellbeing should be the immediate focus.
Choice D Respiratory assessment is essential but is not the priority when the patient is expressing fear and anxiety about the upcoming surgery.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
