A nurse is caring for a client with a new ileostomy.
Which finding regarding the stoma should be reported to the health care provider immediately?
The stoma appears purple or blue in color.
The stoma is slightly edematous.
The stoma is moist and reddish-pink.
There is a small amount of blood during cleaning.
The Correct Answer is A
Choice A rationale
A purple or blue appearance of a stoma is a critical finding that indicates ischemia or total necrosis of the tissue. This suggests that the blood supply to the ileostomy has been compromised, which is a surgical emergency. A healthy stoma requires constant perfusion to remain viable. If the tissue is deprived of oxygenated blood, it will quickly die, leading to perforation or systemic infection. This requires immediate notification of the health care provider for intervention.
Choice B rationale
Slight edema is a common and expected finding in the immediate postoperative period after an ileostomy is created. The surgical trauma and manipulation of the bowel during the procedure cause localized inflammation and swelling. While the nurse should monitor the swelling to ensure it does not obstruct the stoma or interfere with the appliance fit, it is not an emergency that requires immediate reporting unless it is accompanied by other signs of vascular compromise or obstruction.
Choice C rationale
A moist and reddish-pink stoma is the ideal assessment finding and indicates that the stoma is healthy and well-perfused. This color signifies that the mucosal lining is receiving an adequate supply of oxygenated blood. The moisture indicates that the mucosal tissue is functioning correctly and is not becoming desiccated. This finding should be documented as a normal assessment and does not require any special notification to the health care provider or surgical team.
Choice D rationale
A small amount of blood during the cleaning of a stoma is usually normal because the intestinal mucosa is highly vascular and can be easily irritated by friction. As long as the bleeding is minimal and stops quickly after the cleaning process, it does not indicate a major complication. The nurse should use a gentle touch when performing stoma care. Heavy or persistent bleeding would be a concern, but small amounts are typically considered an expected clinical observation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Supporting the client from sliding in bed helps prevent shear and friction, which are major contributors to skin breakdown and pressure injuries. Shearing occurs when the skin remains stationary against the sheets while the underlying tissue and bone move downward, damaging the deep capillary beds. By using pillows, wedges, or adjusting the bed position (such as keeping the head of the bed at or below 30 degrees), the nurse reduces the gravitational force that causes the client to slide.
Choice B rationale
Pulling a client up under the arms during repositioning is a dangerous practice that increases the risk of friction and skin tears. This method concentrates a large amount of force on a small area of skin and can also cause musculoskeletal injury to both the client and the nurse. Instead, nurses should use friction-reducing devices like draw sheets or slide boards and utilize a team approach to lift the client off the bed surface, thereby protecting the integrity of the epidermis.
Choice C rationale
While hydration is essential for maintaining skin turgor and health, carbonated drinks are not an ideal source. These beverages often contain high amounts of sugar or caffeine, which can lead to diuresis and potentially worsen dehydration. Furthermore, carbonation can cause gastric distension and discomfort. For optimal skin health, clients should be encouraged to consume water or balanced electrolyte solutions that support cellular hydration without the negative side effects associated with soda or other highly processed carbonated liquids.
Choice D rationale
Lubricating the skin with petroleum-based oils can actually be counterproductive for skin health in some contexts. These heavy oils can clog pores and trap moisture against the skin, leading to maceration, which makes the skin more fragile and prone to breakdown. While moisturization is important, it is better to use pH-balanced emollients or barrier creams specifically designed for pressure injury prevention. Additionally, petroleum products can degrade certain medical materials and increase the risk of sliding if not applied correctly.
Correct Answer is B
Explanation
Choice A rationale
Mucus production in the gastrointestinal tract is a physiological response to inflammation or irritation of the mucosal lining. While mucus might be present in various bowel conditions, including inflammatory bowel disease or certain infections, it is not the hallmark clinical indicator for an intestinal obstruction. Obstructions typically present with changes in stool shape, frequency, or complete cessation of passage due to the physical blockage within the lumen.
Choice B rationale
Ribbon-shaped stools are a classic clinical indicator of a partial intestinal obstruction, especially when caused by a mass or tumor. As the stool passes through a narrowed lumen created by the obstructing lesion, it is compressed into a thin, flat, or ribbon-like shape. This structural change in the stool provides significant diagnostic evidence of a reduced internal diameter within the colon or rectum requiring further medical investigation.
Choice C rationale
The odor of stool is primarily determined by the bacterial breakdown of proteins and the presence of specific compounds like skatole and indole. While a pungent or foul odor can occur with malabsorption syndromes, infections, or GI bleeds, it does not specifically indicate a mechanical intestinal obstruction. Odor is highly variable and influenced by diet and gut flora rather than the physical diameter of the intestinal passage.
Choice D rationale
Light brown stool is generally considered within the normal color range for human feces, resulting from the conversion of bilirubin into stercobilin. A change to light brown does not signal an obstruction. Significant color changes of concern would include acholic stools, which are clay-colored and indicate a lack of bile flow, or melena, which is black and tarry. Light brown remains a standard finding.
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.