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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
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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