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 A
Explanation
Choice A reason: Pin site care is essential for a client with skeletal traction to prevent infection and ensure proper healing.
Choice B reason: A five-pound weight lifting restriction is not related to the care of a client with skeletal traction.
Choice C reason: Prone positioning is not typically recommended for clients with skeletal traction as it may interfere with the traction setup.
Choice D reason: Intermitent weights are not a standard intervention for skeletal traction, which requires consistent and controlled application of force.
Correct Answer is C
Explanation
Choice A reason (acute renal failure): Patients recovering from acute renal failure are not typically restricted to only vegetable proteins. Protein needs can vary based on the individual's condition and treatment plan.
Choice B reason (acute renal failure): Fluid intake recommendations for patients recovering from acute renal failure depend on their current kidney function and fluid balance status. A blanket restriction to 1500 mL or less per day may not be appropriate for all patients.
Choice C reason (acute renal failure): Avoiding nephrotoxic drugs is crucial for patients recovering from acute renal failure to prevent further kidney damage.
Choice D reason (acute renal failure): Self-catheterization for residual urine is not a standard recommendation for all patients recovering from acute renal failure. This would be specific to patients with urinary retention issues.
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