The nurse assesses an adult client 24 hours after a bowel exploration and formation of a sigmoid colostomy. Which assessment finding should be reported to the surgeon immediately?
The stoma has streaks of bright red blood.
There are no bowel sounds in the left lower quadrant.
The fecal matter is brown and has a solid consistency.
The stoma mucosa is purple in color.
The Correct Answer is D
Choice A reason: While streaks of bright red blood in the stoma can be concerning, it is not necessarily an immediate emergency. It may indicate minor trauma or irritation, but it does not require immediate surgical intervention unless accompanied by other symptoms.
Choice B reason: The absence of bowel sounds in the left lower quadrant can indicate a lack of intestinal activity, which may be a concern, but it is not an immediate surgical emergency. It requires monitoring and further assessment.
Choice C reason: Brown, solid fecal matter is a normal finding and indicates that the colostomy is functioning properly. This is not a cause for immediate concern.
Choice D reason: The stoma mucosa being purple in color is a critical finding that requires immediate reporting to the surgeon. Purple stoma mucosa can indicate compromised blood flow or ischemia, which can lead to tissue necrosis and serious complications if not addressed promptly.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Notifying the surgical team to cancel the surgery is premature without confirming the pregnancy status. While it is critical to consider the possibility of pregnancy before surgery, the decision to cancel should be based on confirmed information rather than a possibility.
Choice B reason: Performing a bedside pregnancy test is the most appropriate immediate intervention. This test can provide rapid confirmation of pregnancy status. If the client is pregnant, the surgical team can then evaluate the risks and benefits of proceeding with or postponing the surgery. Immediate confirmation helps guide clinical decision-making and ensures the safety of both the client and the potential fetus.
Choice C reason: Continuing with surgery as scheduled without confirming the pregnancy status is not appropriate. Anesthesia and surgical procedures can pose risks to a pregnant client and the fetus. It is essential to verify the pregnancy status to make an informed decision about the safety and necessity of the surgery.
Choice D reason: Calculating gestation from the last menstrual cycle can provide an estimate of the pregnancy duration, but it does not confirm pregnancy. A bedside pregnancy test should be performed first to confirm whether the client is pregnant before considering gestational age. This information can then be used to further assess the situation and plan appropriate care.
Correct Answer is ["A","B","C","D","G"]
Explanation
Choice A reason:
Infection prevention is crucial in managing appendicitis. Administering preoperative antibiotics, such as cefazolin, helps prevent surgical site infections and other complications. This aligns with standard care protocols for appendicitis patients.
Choice B reason:
Relieving acute pain is a priority in appendicitis care. Administering analgesics, including opioids, acetaminophen, and NSAIDs, effectively manages pain and reduces inflammation. Providing distraction techniques can also help alleviate discomfort until pain relief is achieved.
Choice C reason:
Client education about the diagnosis and plan of care is essential. Informing the patient about appendicitis, the surgical procedure, and postoperative expectations reduces anxiety and promotes cooperation. Effective communication enhances patient outcomes and satisfaction.
Choice D reason:
Effective coping with illness-related anxiety is important. Providing emotional support and addressing concerns can help the patient manage anxiety associated with the diagnosis and impending surgery. This approach contributes to overall well-being and recovery.
Choice G reason:
Fluid volume management is vital in appendicitis care. Administering intravenous fluids, such as Ringer's lactate, maintains hydration, supports renal function, and prepares the patient for surgery. Proper fluid balance is essential for optimal physiological function.
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