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. Pneumonia typically presents with fever, productive cough, and lung consolidation, not just wheezing and low oxygen saturation.
B. Pneumothorax usually causes sudden sharp chest pain and decreased breath sounds on the affected side, rather than wheezing and prolonged expiration.
C. Asthma is characterized by wheezing, prolonged expiration, and low oxygen saturation due to bronchoconstriction and inflammation. The client's symptoms are consistent with an asthma exacerbation.
D. Bronchitis presents with a productive cough and sometimes wheezing but does not typically cause such severe hypoxemia or a pronounced increase in respiratory rate as seen here.

A. Demonstrate how to select dose based on before meal blood sugar readings. B. Teach the client self-injection skills for daily subcutaneous administration. C. Provide information on increasing medication dosage if ketoacidosis occurs. D. Explain to the family how to inject this medication for severe hypoglycemia.

Correct Answer is B

Explanation

A. Insulin glargine is a long-acting insulin, and its dose is not based on before-meal blood sugar readings.
B. The client needs to be taught how to self-administer insulin glargine, as it is given subcutaneously once daily, usually at the same time each day.
C. Increasing the dosage in response to ketoacidosis is inappropriate; emergency treatment is required for this condition.
D. Insulin glargine does not have a role in treating severe hypoglycemia; fast-acting glucose or glucagon is used for such situations.

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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

Correct Answer is C

Explanation

The nurse is planning discharge teaching for a client with type 2 diabetes mellitus who has a new prescription for insulin glargine. Which action should the nurse plan to Include in the discharge teaching?

Correct Answer is B

Explanation

Which client is at greatest risk for aspiration?

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