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.

Answer and Explanation

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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Correct Answer is []

Explanation

Condition: Transient ischemic stroke (d)

2 actions:

Request a prescription for a computerized tomography (CT) scan of the client's head and neck (d)
Perform a National Institute of Health Stroke Scale (NIHSS) assessment (e)

2 parameters:

Neurological status (a)
Blood pressure (c)

Rationale for correct condition: A transient ischemic stroke (TIA) is a temporary period of symptoms similar to those of a stroke and is often a precursor to a full-blown stroke. The patient's symptoms of dizziness, weakness, and a horrible headache, combined with his history of hypertension and atrial fibrillation, suggest a high risk for a TIA. The patient's confusion about the date and time also supports this condition. Immediate assessment and intervention are crucial to prevent a possible stroke.

Rationale for the two correct actions:

Request a prescription for a CT scan: This is essential to identify any blockages or abnormalities in the blood vessels of the brain, confirming the presence and extent of a TIA or stroke.
Perform an NIHSS assessment: This standardized tool is used to evaluate the severity of a stroke and to monitor changes in the patient's neurological status over time.

Rationale for parameters to monitor:

Neurological status: Monitoring this parameter helps track changes in the patient's cognitive and motor functions, which are critical in assessing the progression or improvement of the stroke symptoms.
Blood pressure: Hypertension is a major risk factor for strokes. Keeping a close watch on the blood pressure helps in managing and reducing the risk of further complications.

Rationale for incorrect conditions:

Hypoglycemia: While it can cause dizziness and weakness, the patient's recent UTI and headache are not typical for hypoglycemia.
Hemorrhagic stroke: This would typically present with more severe neurological symptoms and possible loss of consciousness.
Urinary tract infection: The patient's symptoms go beyond those of a UTI, especially given the headache, dizziness, and confusion.

Rationale for incorrect actions to take:

Administer 0.9% sodium chloride IV: Not specific to stroke management and doesn't address the immediate risk.
Administer oxygen via nasal cannula: The patient's oxygen saturation is normal; thus, this is not immediately necessary.
Request a prescription for the client's home medication of aspirin: While aspirin is used for stroke prevention, administering it without confirming the stroke type (ischemic vs hemorrhagic) could be harmful.

Rationale for incorrect parameters to monitor:

Respiratory rate: This is not directly related to stroke assessment.
Urine output: Irrelevant to the immediate management of TIA.
Oxygen saturation: The patient's oxygen levels are normal, so monitoring it won't provide further insights.

A. Take and monitor vital signs. B. Administer additional nebulizer treatment. C. Increase oxygen flow rate. D. Raise the head of the bed. E. Provide client with a spirometer for use.

Correct Answer is ["B","C","D"]

Explanation

Choice A reason: Monitoring vital signs is crucial to assess the client's current condition and detect any further deterioration. Changes in vital signs can indicate the effectiveness of the treatment and whether additional interventions are needed. For instance, if the heart rate continues to rise or oxygen saturation drops further, it suggests that the client's condition is worsening and requires immediate attention. Keeping a close eye on the vital signs helps the healthcare team to make timely decisions and adjust the treatment plan as necessary.

Choice B reason: Administering additional nebulizer treatment is necessary because the client is still experiencing shortness of breath and bilateral wheezes even after the initial medication. Nebulizer treatments, such as those containing albuterol and ipratropium, help to relax and open the airways, making breathing easier. Given the client's severe asthma symptoms and the fact that the previous doses were not completely effective, additional treatment can provide the needed relief and prevent further respiratory distress.

Choice C reason: Increasing the oxygen flow rate is essential to improve the client's oxygen saturation levels. The current oxygen saturation of 91% indicates hypoxemia, which can lead to severe complications if not addressed promptly. By increasing the flow rate, the client can receive a higher concentration of oxygen, helping to maintain adequate oxygenation of tissues and organs. Continuous monitoring of oxygen saturation is also important to ensure that the increased flow rate is effective and to make further adjustments if needed.

Choice D reason: Raising the head of the bed helps to facilitate easier breathing for the client. This position allows gravity to assist in the expansion of the lungs and reduces the pressure on the diaphragm, making it easier for the client to take deeper breaths. It also helps to reduce the work of breathing and can be particularly beneficial for clients experiencing respiratory distress. Ensuring that the client is in a comfortable and optimal position for breathing is an important aspect of asthma management.

Choice E reason: While providing a spirometer can be useful for lung function exercises, it is not the immediate priority in this acute situation. The client's primary concern is to stabilize their breathing and ensure adequate oxygenation. Once the client is stable, a spirometer can be introduced as part of long-term management and rehabilitation to improve lung function and monitor progress.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Complete the diagram by choosing from the choices below to specify which condition the client is most likely experiencing, two actions the nurse should take to address the condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

Exhibits After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

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