The home care nurse is assessing a client's abdomen 4 weeks after a colostomy in the descending colon was created. What are the expected findings of the a healthy client's abdominal assessment?

(SELECT ALL THAT APPLY)

stoma is shiny and moist

stoma is deep pink

peristomal skin is not reddened or tender

abdomen flat

bowel sounds present 8 to 10 clicks/gurgles per minute

Answer and Explanation

Correct Answer : A,B,C,D,E

A. A healthy stoma should appear moist and shiny, indicating adequate blood supply and hydration of the tissue. Dryness or dullness of the stoma may indicate poor blood flow or dehydration and should be further evaluated.
B.   A healthy stoma typically appears deep pink to red in color, indicating good tissue perfusion. Pallor or cyanosis of the stoma may indicate inadequate blood supply and should be assessed promptly.
C.   The skin around the stoma, known as the peristomal skin, should be intact, without signs of irritation, redness, or tenderness. Irritation or breakdown of the peristomal skin can occur due to leakage of stool or irritation from ostomy appliances and should be addressed promptly to prevent skin complications.
D.   A flat abdomen suggests normal abdominal contour without distention or bulging. Distention or bulging of the abdomen may indicate underlying issues such as bowel obstruction, gas accumulation, or fluid retention and should be assessed further.

E.   Bowel sounds are indicative of gastrointestinal motility and function. Normal bowel sounds are present and audible in healthy individuals and are characterized by 8 to 10 clicks or gurgles per minute. Absence or abnormal bowel sounds may indicate bowel obstruction, ileus, or other gastrointestinal disorders and should be assessed further.

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Correct Answer is B

Explanation

B. One of the primary functions of an IV infusion pump is to precisely control the rate and volume of fluid delivery, thereby reducing the risk of accidental administration of large amounts of fluids. The pump allows for accurate programming of infusion rates and volume limits, enhancing safety and preventing fluid overload or other complications.
A. Using an IV infusion pump does not eliminate the need for assessing the IV site regularly. Regardless of the infusion method, it is essential to monitor the IV site frequently for signs of complications such as infiltration, phlebitis, or dislodgement. Therefore, this option is not the appropriate rationale for using an IV infusion pump.

C. IV infusion pumps are programmable devices that allow for precise control of the drip rate independent of the client's position. They ensure a consistent and controlled flow rate regardless of changes in the client's position, providing reliable delivery of fluids or medications.
D. While IV infusion pumps can deliver fluids at various rates, including rapid infusion rates when necessary, their primary purpose is not to administer fluids at a rapid rate. Rather, they are designed to deliver fluids or medications at controlled and programmed rates tailored to the client's needs, ensuring safety and accuracy.

A. "In a few months I will be strong enough to travel to my shore house and go fishing." B. "My family will not be permitted to be with me when I die." C. 1 will be in a hospital room when II die." D. " will have pain medication available when I need it."

Correct Answer is D

Explanation

D. This statement indicates an understanding of hospice care. Pain management is a crucial component of hospice care, and ensuring that patients have access to effective pain medication and symptom management is a priority. Hospice aims to maximize comfort and quality of life for patients, and providing pain relief is a fundamental aspect of this approach.
A. This statement suggests that the client may not fully understand the purpose of hospice care. Hospice care is generally provided to patients with a terminal illness who have a life expectancy of six months or less. The focus of hospice care is on comfort, quality of life, and symptom management rather than curative treatment. Planning for travel and activities like fishing may not align with the goals of hospice care.
B. This statement indicates a misunderstanding of hospice care. In hospice, patients are typically encouraged to have their loved ones and family members present and involved in their care, especially during the end-of-life period. Hospice care emphasizes emotional support, spiritual care, and the importance of family involvement during the dying process.
C. This statement may or may not indicate an understanding of hospice care, as it depends on the specific hospice setting and individual preferences. While some hospice programs may provide care in a hospital setting, many hospice services are delivered in the patient's home or in a hospice facility. The key aspect of hospice care is to provide comfort and support in a setting that best meets the patient's needs and wishes.

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The home care nurse is assessing a client's abdomen 4 weeks after a colostomy in the descending colon was created. What are the expected findings of the a healthy client's abdominal assessment? (SELECT ALL THAT APPLY)

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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The home care nurse is assessing a client's abdomen 4 weeks after a colostomy in the descending colon was created. What are the expected findings of the a healthy client's abdominal assessment?

(SELECT ALL THAT APPLY)