A nurse is preparing to receive a client from surgery following a transverse colon resection with colostomy placement. The nurse should expect to assess the stoma at which of the following locations?
(You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
A
B
C
D
The Correct Answer is B
A transverse colon colostomy is typically placed in the upper abdomen, either in the middle or toward the right side of the body. In the above scenario the best location will be B which is located along the path of the transverse colon. Point A would be suitable for an ileostomy while point B will be suitable for a sigmoid colostomy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Monitoring for hyperkalemia, not hypokalemia, is important in the case of acute rejection.
B. Assessing urine output hourly is crucial to evaluate kidney function and detect any signs of complications early.
C. Blood pressure should be checked more frequently than every 8 hours in the immediate postoperative period.
D. While pain management is important, IV opioids are typically used in the immediate postoperative period rather than PO opioids.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Answer: 0.9% Sodium chloride followed by Insulin
The initial treatment for DKA involves fluid resuscitation to address dehydration and electrolyte imbalances, correction of hyperglycemia, and insulin administration to promote glucose utilization and halt ketone production.
Therefore, the nurse should first administer 0.9% sodium chloride (normal saline) to address dehydration and restore intravascular volume, as indicated by the client's low blood pressure (96/65 mm Hg), increased heart rate (110/min), and slight tenting of the skin, suggestive of dehydration.
Once fluid resuscitation is initiated and the client is hemodynamically stable, the next step is to address the hyperkalemia. The client's potassium level is elevated at 5.5 mEq/L, likely due to the acidosis and cellular shift of potassium. Insulin therapy helps to drive potassium back into the cells, thereby lowering serum potassium levels.
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