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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A The supine position (lying flat on the back) is not suitable for administering an enema as it does not facilitate proper flow and retention of the solution.

Choice B High Fowler's position (sitting upright at a 90degree angle) is not appropriate for enema administration, as it might cause discomfort and hinder proper administration.

Choice C Semi Fowler's position (sitting at a semiupright angle) is also not the best option for enema administration, as it may not allow the solution to flow effectively.

Choice D The Sims position, with the patient lying on the left side with the right knee flexed, allows the enema solution to flow downward by gravity and improves retention. It is the best position for enema administration.

A. Pneumonia B. Edema or Excess Fluid Volume C. Hypertension D. Diabetes Melitus

Correct Answer is B

Explanation

Choice A Pneumonia is not a contraindication for a tap water enema.

Choice B A tap water enema is not recommended for patients with edema or excess fluid volume due to the risk of further fluid overload.

Choice C Hypertension is not a contraindication for a tap water enema unless the patient has other cardiovascular conditions that could be exacerbated by the procedure.

Choice D Diabetes mellitus is not a contraindication for a tap water enema. However, patients with diabetes may need careful monitoring during the procedure due to potential glucose

fluctuations.

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A nurse is caring for 4 patients each patient has a colostomy bag. Which patient should be seen first and made a priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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