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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Antidiarrheal medications like Lomotil should be avoided initially in infectious diarrhea, as they can slow the elimination of pathogens and worsen the condition.
B. Obtaining a stool sample for culture is the first priority to identify the causative organism, especially in a client with recent travel history, which raises suspicion for infectious or parasitic diarrhea.
C. An erythrocyte sedimentation rate (ESR) measures inflammation but is not specific or urgently needed for diagnosing infectious diarrhea.
D. Initiating antibiotics before identifying the pathogen may lead to inappropriate treatment and resistance; therapy should be guided by culture results.
Correct Answer is C
Explanation
Rationale:
A. This response is nontherapeutic and discouraging, and it does not support the client emotionally or clarify her concerns.
B. While involving the provider is appropriate, deferring the conversation entirely fails to address the client’s immediate emotional needs.
C. Asking, “What is it about the adverse effects that concerns you?” is a therapeutic, open-ended response that encourages the client to express her feelings, allowing the nurse to provide support and individualized education.
D. Referring to the American Cancer Society is helpful, but it should not replace direct engagement and support from the nurse in the moment.
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