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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Administering oxygen at 2 L/min via nasal cannula is a common intervention for patients experiencing respiratory distress or hypoxia. However, in this scenario, the client’s oxygen saturation is 96%, which is within the normal range. Administering oxygen unnecessarily can lead to complications such as oxygen toxicity, especially in patients with chronic conditions like COPD. The client’s rapid and shallow breathing is likely a response to pain and anxiety rather than a primary respiratory issue. Therefore, addressing the underlying cause of his symptoms, such as pain management and anxiety reduction, would be more appropriate.
Furthermore, the client’s medical history includes hypertension and type 2 diabetes mellitus. These conditions can complicate the administration of oxygen therapy. For instance, patients with hypertension may experience increased blood pressure with supplemental oxygen, and those with diabetes may have altered respiratory responses. It is crucial to consider these factors before initiating oxygen therapy.
In summary, while oxygen therapy is a vital intervention for hypoxia, it is not indicated in this case due to the client’s normal oxygen saturation levels and the need to address pain and anxiety first.
Choice B rationale:
Preparing the client for immediate surgery is a drastic measure that should only be considered if there is a clear indication of a life- threatening injury or condition that requires surgical intervention. In this case, the client has a visible abrasion on his right elbow and complains of pain in his right hip. While these symptoms are concerning, they do not necessarily indicate an immediate need for surgery.
The client’s vital signs, although elevated, do not suggest a life-threatening condition. His temperature is slightly elevated, which could be due to pain or anxiety. His pulse and respirations are elevated, likely due to pain and anxiety as well. His blood pressure is elevated, which is consistent with his history of hypertension. These vital signs do not indicate a need for immediate surgical intervention.
Additionally, the client’s medical history of hypertension, type 2 diabetes mellitus, and osteoarthritis must be considered. These conditions can complicate surgical procedures and increase the risk of complications. Therefore, a thorough assessment and diagnostic imaging, such as X-rays or CT scans, should be performed to determine the extent of the injury before considering surgery.
In summary, immediate surgery is not warranted based on the current assessment. Further evaluation and diagnostic imaging are necessary to determine the appropriate course of action.
Choice C rationale:
Applying a cold pack to the client’s right hip is an appropriate intervention for several reasons. First, the client is experiencing pain in his right hip, which could indicate a soft tissue injury, contusion, or even a fracture. Applying a cold pack can help reduce pain and swelling in the affected area, providing immediate relief.
Cold therapy, also known as cryotherapy, works by constricting blood vessels, which reduces blood flow to the injured area. This helps to decrease inflammation and swelling, which can alleviate pain. Additionally, cold therapy can numb the affected area, providing further pain relief.
The client’s medical history of osteoarthritis is also relevant. Osteoarthritis can cause joint pain and stiffness, and cold therapy is often recommended to manage these symptoms. By applying a cold pack to the right hip, the nurse can help manage the client’s pain and prevent further complications.
In summary, applying a cold pack to the client’s right hip is a safe and effective intervention to manage pain and swelling. It addresses the client’s immediate discomfort and is consistent with best practices for managing soft tissue injuries and osteoarthritis.
Choice D rationale:
Assisting the client to a standing position and assessing his ability to bear weight on the right leg is not appropriate at this stage. The client has reported pain in his right hip, which could indicate a serious injury such as a fracture. Attempting to stand or bear weight on the affected leg could exacerbate the injury and cause further harm.
Before assessing the client’s ability to bear weight, it is essential to conduct a thorough assessment and obtain diagnostic imaging to determine the extent of the injury. This may include X-rays or CT scans to rule out fractures or other serious conditions. Once the extent of the injury is known, a more appropriate plan of care can be developed.
Additionally, the client’s medical history of osteoarthritis should be considered. Osteoarthritis can cause joint pain and stiffness, making it difficult for the client to bear weight on the affected leg. Forcing the client to stand or walk without proper assessment and support could lead to further injury and complications.
In summary, assisting the client to a standing position and assessing his ability to bear weight on the right leg is not appropriate at this stage. A thorough assessment and diagnostic imaging are necessary to determine the extent of the injury and develop a safe and effective plan of care.
Correct Answer is B
Explanation
Choice A rationale
While gastric acid can cause dyspepsia, measuring gastric residual is not primarily done to remove gastric acid.
Choice B rationale
Measuring gastric residual is primarily done to identify delayed gastric emptying. This is important because delayed gastric emptying can lead to complications such as aspiration pneumonia.
Choice C rationale
Gastric residual does not directly determine the patient’s electrolyte balance.
Choice D rationale
While confirming the placement of the NG tube is important, it is not the primary purpose of measuring gastric residual.
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