A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?

The stoma appears dark in color.

The stoma bleeds lightly when touched.

The stoma is draining a small amount of liquid stool.

The stoma protrudes slightly from the abdomen.

Answer and Explanation

The Correct Answer is A

A. The stoma appears dark in color.: A healthy stoma should be moist and reddish-pink. A dark (purple, black, or dusky) stoma indicates ischemia or poor perfusion and must be reported immediately to prevent tissue death.

B. The stoma bleeds lightly when touched.: This is a common and expected finding, as stoma tissue is highly vascular and fragile, especially in the early postoperative period.

C. The stoma is draining a small amount of liquid stool.: This is an expected finding 2 days postoperatively as the bowel begins to resume function.

D. The stoma protrudes slightly from the abdomen.: A slight protrusion (budding) is normal and helps the stool fall into the collection pouch rather than sitting on the skin.

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Correct Answer is B

Explanation

A. Suctioning a tracheostomy for a client who has a recent head injury: Incorrect. This is an invasive procedure requiring clinical judgment and sterile technique; it must be performed by a nurse.

B. Providing postmortem care for a client who has just died: Postmortem care (cleaning the body, positioning) is within the scope of practice for an AP.

C. Changing a peripheral IV dressing for a client who is postoperative: Assessment of an IV site and sterile dressing changes require the skills of a licensed nurse.

D. Administering vaginal cream to a client who has a vaginal infection: Medication administration is generally restricted to licensed personnel (RN/LPN).

A. "You will have to sign a release form to perform the care yourself." B. "I will assist you in any way I can during this process." C. "This care takes place after the client leaves the facility." D. "A licensed health care worker must perform postmortem care."

Correct Answer is B

Explanation

A. "You will have to sign a release form to perform the care yourself.": There is no standard legal release form required for family involvement in postmortem hygiene.

B. "I will assist you in any way I can during this process.": This is a culturally sensitive and therapeutic response. Allowing the family to participate in postmortem care can provide closure and honor religious or personal rituals.

C. "This care takes place after the client leaves the facility.": Postmortem care is performed immediately after death in the facility to prepare the body for the family to view and for transport.

D. "A licensed health care worker must perform postmortem care.": While the nurse is responsible for the overall process, there is no law preventing family members from assisting or performing the care themselves if they wish.

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A nurse is collecting data from a client who is 2 days postoperative following the placement of a colostomy. Which of the following findings should the nurse report to the provider?

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