In preparing to perform colostomy care, the nurse observes that a client's colostomy stoma has become a dark red to bluish color. Which action should the nurse implement?

Remove the drainage bag and apply antibiotic ointment around the stoma.

Apply a pulse oximeter to determine the client's oxygen saturation level.

Replace the colostomy supplies with non-latex hypoallergenic supplies.

Notify the healthcare provider of the appearance of the stoma immediately.

Answer and Explanation

The Correct Answer is D

A. Applying antibiotic ointment is not appropriate for this situation as the issue is likely compromised blood flow, not infection.
B. Checking oxygen saturation is not related to the color change of the stoma.
C. Switching to non-latex supplies is important for clients with latex allergies but is not relevant to the immediate problem.
D. A dark red to bluish color of the stoma suggests compromised blood flow and possible ischemia, which requires immediate medical attention. The nurse should notify the healthcare provider immediately to address this potentially serious complication.

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Correct Answer is C

Explanation

A. Hypertension is not a common side effect of phenytoin. It is not typically associated with the medication.
B. Peripheral edema is not commonly linked to phenytoin use.
C. Gingival hyperplasia, or overgrowth of the gums, is a common side effect of phenytoin, particularly with long-term use.
D. Hematuria is not a typical side effect of phenytoin and may indicate a different medical issue.

A. Renal creatinine clearance. B. Complete blood count. C. Chemistry panel. D. Liver function tests.

Correct Answer is D

Explanation

A. Renal creatinine clearance is important in assessing kidney function but is not directly related to divalproex sodium therapy.
B. While CBC monitoring is essential, especially for detecting thrombocytopenia, liver function tests are more critical in this context.
C. A chemistry panel is valuable but does not specifically monitor for the primary risks associated with divalproex sodium.
D. Divalproex sodium (valproate) can cause hepatotoxicity, so monitoring liver function tests (LFTs) is crucial. Regular LFTs help detect early signs of liver damage, which can be a serious adverse effect of this medication.

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In preparing to perform colostomy care, the nurse observes that a client's colostomy stoma has become a dark red to bluish color. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To detect common untoward effects of phenytoin, the nurse should assess a client with a seizure disorder for which sign or symptom?

Correct Answer is C

Explanation

The nurse is caring for a client who is taking the mood stabilizer divalproex sodium. Which laboratory value is most important for the nurse to monitor?

Correct Answer is D

Explanation

An older client is admitted to the medical-surgical unit after falling and fracturing the left hip. The nurse is reviewing written preoperative instructions with the client and spouse. Which action should the nurse implement while providing these instructions?

A client who is 12 weeks pregnant has type 1 diabetes mellitus. Which instruction should the nurse provide related to insulin dosages?

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The client's laboratory results indicate that the serum potassium level is 2.5 mEq/L (2.5 mmol/L). Which action should the nurse take? Reference Range: Potassium (K+) [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

A client taking temazepam informs the nurse of plans to quit taking the medication due to feelings of "hungover" the next day. Which action should the nurse implement?