The nurse is assessing a client who is 2 days postoperative from a colostomy. Which of the following findings should the nurse report to the healthcare provider immediately?

The skin around the stoma is intact, with no redness or irritation.

The stoma is moist, pink, and protrudes slightly above the abdominal wall.

A small amount of gas and liquid stool is present in the ostomy pouch

Stoma appears dark purple, dusky, and dry to the touch.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Intact skin around the stoma is a normal and expected finding, indicating proper appliance fit and skin care.
B. A stoma that is moist, pink, and slightly protruding is the desired appearance postoperatively.
C. The presence of gas and liquid stool is expected as bowel function begins to return.
D. A dark purple, dusky, and dry stoma suggests compromised blood flow or necrosis, which is a surgical emergency. This finding requires immediate notification of the healthcare provider.

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Correct Answer is C

Explanation

Rationale:
A. While reviewing fluid balance is important, it is not the priority in response to symptoms of hyperglycemia.
B. Reducing the TPN rate without verifying the cause of symptoms could lead to undernourishment or abrupt changes in glucose levels.
C. Blurred vision, dry mouth, and frequent urination are classic signs of hyperglycemia. Since TPN contains high levels of glucose, a finger-stick blood glucose check is the priority to confirm and address potential hyperglycemia.
D. Vital signs are important, but do not directly assess the suspected cause of the client's symptoms in this case.

A. Osteomyelitis B. Septicemia C. Phantom pain D. Avascular necrosis

Correct Answer is D

Explanation

Rationale:
A. Osteomyelitis is a bone infection, more commonly associated with open fractures or post-surgical complications, not typically a preoperative concern with closed femoral neck fractures.
B. Septicemia (blood infection) is possible but not a primary complication of a closed hip fracture before surgery.
C. Phantom pain is associated with amputations, not hip fractures.
D. Avascular necrosis is a significant risk with femoral neck fractures due to compromised blood supply to the femoral head. Without adequate blood flow, bone tissue can die, leading to joint dysfunction and chronic pain.

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The nurse is assessing a client who is 2 days postoperative from a colostomy. Which of the following findings should the nurse report to the healthcare provider immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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