A patient has undergone a single-barrel descending colon colostomy for the palliative treatment of stage IV colon cancer. The nurse assesses the colostomy stoma to ensure that it is:
Beefy red and moist
Dusky maroon colored
Pale and pink
Pink and dry
The Correct Answer is A
Choice A reason: A healthy stoma should be beefy red and moist, indicating good blood supply and hydration.
Choice B reason: A dusky maroon color could indicate compromised blood supply or ischemia.
Choice C reason: A pale and pink stoma may suggest anemia or reduced blood flow.
Choice D reason: A stoma that is pink and dry could be dehydrated, which is not ideal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason : While maintaining a stable ECG rhythm is important, it is not the highest priority. The primary concern is to address life-threatening complications.
Choice B reason : Educating the patient about the causes and effects of coronary heart disease (CHD) or coronary artery disease (CAD) is important for long-term management but is not the immediate priority during acute care.
Choice C reason : Adequate relief of pain is the highest priority in the care of a patient with AMI. Pain is an indicator of ongoing ischemia and can increase the workload of the heart, thereby worsening the condition.
Choice D reason (AMI): While bedrest is part of the care plan, it is not the highest priority compared to pain relief, which has direct implications on the patient's immediate physiological status.
Correct Answer is B
Explanation
Choice A reason: Dumping syndrome is not commonly associated with dysphagia post-stroke.
Choice B reason: Aspiration is a significant risk for patients with dysphagia following a stroke and should be closely monitored to prevent complications like aspiration pneumonia.
Choice C reason: Gastroesophageal reflux disease may occur but is not the most immediate concern for stroke patients with dysphagia.
Choice D reason: Peptic ulcer disease is not directly related to dysphagia and is less likely to be an immediate complication post-stroke.
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