A nurse is caring for a client who has colorectal cancer and is recovering from surgery to redirect intestinal contents out of the body. Which of the following post-surgical manifestations require nursing intervention to avoid a serious complication?

The client requires the use of a colostomy bag.

The client has a loss of appetite following surgery.

The client has absent bowel sounds in the lower abdominal quadrants.

The client is experiencing mild pain at the surgical site when sitting up.

Answer and Explanation

The Correct Answer is C

Choice A reason: The use of a colostomy bag is expected following surgery for colorectal cancer that involves the creation of a stoma. This does not indicate a complication.
Choice B reason: A loss of appetite is common after major surgery and can be managed with nutritional support and gradual reintroduction of food.
Choice C reason: Absent bowel sounds in the lower abdominal quadrants could indicate a paralytic ileus or bowel obstruction, which are serious complications requiring immediate intervention to prevent further issues such as bowel ischemia.
Choice D reason: Mild pain at the surgical site is expected and can be managed with prescribed pain medications. It does not indicate a serious complication.

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Correct Answer is A

Explanation

Choice A reason: A sigmoid colostomy is typically located in the left lower abdomen. This statement accurately informs the client about the expected location of their stoma.
Choice B reason: A colostomy in the sigmoid colon produces formed stool. This area of the colon is responsible for the final stages of digestion where stool becomes more solid.
Choice C reason: The stoma should be pink to red and moist, indicating healthy tissue. A purple color may indicate compromised blood flow and requires immediate medical attention.
Choice D reason: The stoma itself is not typically painful after surgery, although the area around the surgical site may be tender. Pain management focuses on the overall surgical area rather than the stoma itself.

A. Reduce the client's intake of protein. B. Administer vitamin K. C. Restrict the client's intake of fluids. D. Administer diuretics.

Correct Answer is A

Explanation

Choice A reason: Reducing the client's intake of protein can help decrease the production of ammonia, which is a byproduct of protein metabolism. High ammonia levels contribute to hepatic encephalopathy, so a lower protein diet can be beneficial.
Choice B reason: Administering vitamin K is important for managing bleeding risks associated with cirrhosis, but it does not specifically address ammonia levels.
Choice C reason: Restricting fluid intake may be necessary for managing ascites and edema in cirrhosis but does not directly impact ammonia levels.
Choice D reason: Administering diuretics is often necessary to manage fluid retention and ascites, but it does not affect ammonia production or levels in the blood.

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A nurse is caring for a client who has colorectal cancer and is recovering from surgery to redirect intestinal contents out of the body. Which of the following post-surgical manifestations require nursing intervention to avoid a serious complication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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