A nurse is managing the care of a female client with an ileostomy who has been experiencing complications and has recently undergone a stoma revision. The client’s condition is evolving over several days, and the nurse is reviewing all relevant exhibits to assess the need for further intervention.
Based on the exhibits provided, which findings require immediate intervention by the nurse? Select all that apply.
The stoma has a bluish discoloration and is bleeding extensively.
The skin surrounding the stoma has large open sores with oozing.
The client is exhibiting a temperature of 37.8°C (100.0°F).
The client has a heart rate of 90 beats per minute.
The client reports increased nausea and vomiting.
The stoma culture is negative for mixed bacteria.
The client refuses to participate in stoma care education.
Correct Answer : A,B,C,E,G
Choice A rationale: The stoma has a bluish discoloration and is bleeding extensively. This is a significant finding that requires immediate intervention. A bluish or dusky color indicates poor blood flow to the stoma, which can lead to tissue necrosis if not addressed promptly. Extensive bleeding is also a concerning symptom that could indicate damage to the stoma or surrounding tissue. It’s important for the nurse to assess the stoma and notify the healthcare provider immediately to prevent further complications.
Choice B rationale: The skin surrounding the stoma has large open sores with oozing. This is another critical finding that needs immediate attention. Open sores and oozing can indicate a severe skin breakdown or infection, which can lead to further complications if not treated promptly. The nurse should clean the area, apply appropriate dressings, and consult with the wound care team or healthcare provider for further management.
Choice C rationale: The client is exhibiting a temperature of 37.8°C (100.0°F). While this temperature is not extremely high, it is slightly elevated and could be an early sign of infection, especially when considered in the context of the other symptoms the client is experiencing. The nurse should continue to monitor the client’s temperature and other vital signs, and report any significant changes to the healthcare provider.
Choice E rationale: The client reports increased nausea and vomiting. These symptoms can lead to dehydration and electrolyte imbalances, which can further complicate the client’s condition. The nurse should assess the client’s hydration status, provide interventions to manage nausea and vomiting, and monitor the client’s electrolyte levels.
Choice G rationale: The client refuses to participate in stoma care education. While this may not seem like an immediate medical concern, it is a significant issue that requires intervention. The client’s refusal to learn about stoma care can hinder their recovery and long-term management of the ileostomy. The nurse should explore the reasons behind the client’s refusal, provide emotional support, and use different strategies to encourage the client’s participation in stoma care education.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Vibration of the eardrum is not directly transmitted to the eighth cranial nerve, bypassing the inner ear structures. The vibrations from the eardrum are first transmitted through the ossicles (tiny bones in the middle ear) to the cochlea in the inner ear.
Choice B rationale
Sound waves enter the ear canal, but they are not directly converted to electrical impulses. The sound waves cause the eardrum to vibrate, and these vibrations are transmitted through the ossicles to the cochlea, where they are converted into electrical signals that are sent to the brain via the eighth cranial nerve.
Choice C rationale
Vibration of the eardrum transmits through the bony ossicles to the perilymph in the inner ear, stimulating the eighth cranial nerve. This is the correct description of the process of hearing.
Choice D rationale
Sound is not transmitted directly from the eardrum to the brain. The sound-induced vibrations of the eardrum are transmitted through the ossicles to the cochlea, where they are converted into electrical signals that are sent to the brain via the eighth cranial nerve.
Correct Answer is D
Explanation
Choice A rationale
Granulation tissue forming at the bottom of the wound bed is a characteristic of secondary intention healing, not primary intention. In secondary intention, the wound is left open and fills with granulation tissue.
Choice B rationale
A wound that was contaminated at the time of injury would likely require secondary intention healing to allow for cleaning and observation of the wound. This is not typical of primary intention healing.
Choice C rationale
Prolonged healing of the wound is not a characteristic of primary intention healing. In primary intention, the wound edges are brought together (approximated), which allows for rapid healing.
Choice D rationale
In primary intention healing, the skin edges of the wound are sutured closed. This is the most distinctive feature of primary intention healing, as it allows for minimal scar formation and quick healing.
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