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 C

Explanation

A. Lower extremity weakness: This is a physiological or physical risk factor, not a lifestyle choice.

B. Reduced health literacy: This is a socioeconomic or cognitive factor.

C. Texting while driving: A lifestyle risk factor is a behavior or habit that an individual chooses to engage in which increases their risk of harm.

D. Impaired hearing: This is a sensory/physiological risk factor.

A. "Why don't you want to be touched?" B. "Would you like some pain medication before getting out of bed?" C. "I will stand next to you and help if you need me to." D. "We can talk about this after you have gotten out of bed."

Correct Answer is C

Explanation

A. "Why don't you want to be touched?": Asking "Why" can make a client feel defensive and is considered non-therapeutic communication.

B. "Would you like some pain medication before getting out of bed?": This ignores the client's immediate assertion of independence and safety risk.

C. "I will stand next to you and help if you need me to.":. This response respects the client's autonomy while ensuring safety by maintaining proximity in case the client becomes unsteady.

D. "We can talk about this after you have gotten out of bed.": This dismisses the client's immediate concern and the potential risk of a fall.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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