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: Taking several deep breaths is not specifically related to the preparation for a renal system physical assessment. Deep breaths are more commonly associated with lung examination or to help the patient relax.
Choice B reason: Drinking several glasses of water before a renal assessment could potentially fill the bladder, which might interfere with palpation of the kidneys and make it uncomfortable for the patient.
Choice C reason: Emptying the bladder is the correct action before a renal system physical assessment. It allows for better palpation of the kidneys and other structures without the discomfort of a full bladder. It also prevents the possibility of the patient urinating involuntarily during the examination due to a full bladder.
Choice D reason: Providing a urine sample might be part of the overall renal assessment, but it is not necessary to do so immediately before the physical examination of the renal system. The sample can be collected at any time before or after the physical examination.
Correct Answer is C
Explanation
Choice A reason: Enhancing the formation of granulation tissue is not the immediate expected outcome of an escharotomy.
Choice B reason: Ensuring brisk bleeding is not the goal; minimal bleeding is expected, and it should be controlled to maintain fluid volume status.
Choice C reason: Ensuring the return of distal pulses is the expected outcome of an escharotomy, as it relieves pressure and restores circulation to the affected limbs.
Choice D reason: Decreasing edema formation is a benefit of the procedure but not the primary expected outcome.
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