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 A

Explanation

A. Allergic rhinitis is characterized by intranasal edema and swelling of the turbinates due to inflammation caused by allergens. This is a common physical finding in clients with allergic rhinitis.
B. Purulent secretions typically indicate an infection rather than an allergic condition.
C. Bilateral, pale gray nodules might suggest nasal polyps, which are associated with chronic sinusitis rather than acute allergic rhinitis.
D. Eye tearing is common in allergic rhinitis, but thick yellow nasal drainage suggests an infection rather than an allergic reaction.

A. Acetaminophen. B. Captopril. C. Omeprazole. D. Prednisone.

Correct Answer is A

Explanation

A. Acetaminophen, especially in high doses or with prolonged use, is known to cause hepatotoxicity, which can lead to jaundice. Notifying the healthcare provider is crucial to prevent further liver damage.
B. Captopril, an ACE inhibitor used for hypertension, is not commonly associated with jaundice or liver dysfunction.
C. Omeprazole, a proton pump inhibitor used for GERD, is less likely to cause liver damage compared to acetaminophen.
D. Prednisone, a corticosteroid, can have many side effects, but hepatotoxicity is not among the most common, making acetaminophen the most concerning drug in this context.

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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

A client is being evaluated for environmental allergies. While examining the client's nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

A parent brings a preteen daughter to the clinic for her first female examination. During the health assessment, the nurse should implement which technique to determine if the client has reached the age of menarche?

When systematically auscultating a client's anterior breath sounds, the nurse should begin by placing the stethoscope over which location?

After receiving large doses of chlorpromazine for two weeks, a client begins to develop spasms of the neck and back. Which action should the nurse take?

An older adult client with heart failure comes to the emergency room because of nausea, vomiting, and anorexia. Based on the client's signs and symptoms, which data from the medical history has the most significance when planning this client's care?

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?

The nurse is preparing a bladder irrigation for an adult client who has a long-term indwelling urinary catheter. The urine is cloudy with fibrin clots and sediment. Which intervention should the nurse implement?

To assess a male client's muscle strength, the nurse first asks the client to extend his arms. Before asking the client to flex his arms, what should the nurse do?