A nurse is caring for a client who is postoperative following the placement of a colostomy. Which of the following findings indicates that the colostomy is functioning properly?
Passing of flatus
Stoma is pinkish-red
Tolerating a clear liquid diet
Absent bowel sounds
The Correct Answer is B
Choice A reason: Passing of flatus is not a reliable indicator of colostomy function, as it can occur even when there is an obstruction or ischemia in the bowel.
Choice B reason: Stoma is pinkish-red is a sign of a healthy and well-perfused colostomy, as it indicates that the blood supply to the bowel segment is adequate and there is no necrosis or infection.
Choice C reason: Tolerating a clear liquid diet is not a specific indicator of colostomy function, as it does not reflect the amount or consistency of the stool output.
Choice D reason: Absent bowel sounds are not a normal finding for a colostomy, as they can indicate a paralytic ileus or a bowel obstruction, which can cause complications such as distension, pain, or perforation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice a is not correct because consuming canned sardines twice a week is not a risk factor for osteoporosis, but rather a protective factor. Canned sardines are rich in calcium and vitamin D, which are essential for bone health.
Choice c is not correct because applying an estrogen vaginal cream daily is not a risk factor for osteoporosis, but rather a treatment option. Estrogen therapy can help prevent bone loss and reduce the risk of fractures in postmenopausal women.
Choice d is not correct because walking 30 minutes per day is not a risk factor for osteoporosis, but rather a beneficial exercise. Weight-bearing physical activity can stimulate bone formation and improve bone strength.
Correct Answer is A
Explanation
Choice A: This is correct. Dehydration can cause electrolyte imbalance and affect the brain function, leading to confusion, dizziness, or lethargy.
Choice B: This is incorrect. Cool, clammy skin is a sign of shock, not dehydration. Dehydration can cause dry, warm skin.
Choice C: This is incorrect. Decrease in pulse rate is a sign of bradycardia, not dehydration. Dehydration can cause increase in pulse rate as the body tries to compensate for the low blood volume.
Choice D: This is incorrect. Increase in blood pressure is a sign of hypertension, not dehydration. Dehydration can cause decrease in blood pressure as the blood volume drops.
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