The nurse is assessing a client who is 24-hours post-op after creation of a descending end colostomy due to colon cancer. Which of the following is an expected finding for this client?

The stoma will be edematous in appearance.

Bowel sounds will be hyperactive.

The colostomy appliance will need to be replaced

The colostomy will be producing fecal matter from the proximal stoma and mucus from the distal stoma.

Answer and Explanation

The Correct Answer is A

A. The stoma will be edematous in appearance; this is an expected finding 24 hours after surgery. Mild to moderate edema is normal due to surgical manipulation and should gradually decrease over time.
B. Bowel sounds are often hypoactive or absent immediately post-op due to anesthesia and bowel manipulation, not hyperactive.
C. The colostomy appliance typically remains in place unless there's a leak or issue; routine replacement is not expected at 24 hours post-op.
D. A descending end colostomy involves only one stoma from the proximal end of the bowel; there is no distal stoma, so this option does not apply.

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Correct Answer is B

Explanation

A. A widening pulse pressure (the difference between systolic and diastolic blood pressure) can be a sign of increasing intracranial pressure (ICP), but it typically occurs later in the progression of ICP. Early signs of increased ICP are often more subtle and include changes in behavior and consciousness.

B. One of the earliest signs of increased ICP is altered mental status or behavioral changes, such as increasing restlessness or agitation. As pressure builds inside the skull, it affects the brain's ability to function normally, leading to these early signs. Restlessness may indicate that the brain is becoming less able to maintain normal function due to the increasing pressure.

C. A decrease in pulse rate may occur later in the course of increased ICP, particularly with severe increases in pressure. However, early signs typically involve changes in consciousness and mental status rather than changes in vital signs like heart rate.

D. Dilated and fixed pupils are a late sign of increased ICP and usually indicate significant brain herniation or severe neurological compromise. While they are serious and require immediate attention, they do not typically occur at the early stages of increased ICP.

A. a small amount of green tinged fluid from the nasogastric tube. B. no bowel sounds noted during the assessment. C. an SPO2 which registers 89% while the client is asleep. D. increasing abdominal distention

Correct Answer is D

Explanation

A. A small amount of green-tinged fluid from the nasogastric tube is typically expected after bowel resection surgery. The green fluid is usually bile and is a normal finding as the gastrointestinal system adjusts post-operatively.
B. No bowel sounds noted during the assessment can be a normal finding in the immediate post-operative period, particularly after bowel surgery, due to the effects of anesthesia and surgical manipulation. Bowel sounds may be absent for a short time but should gradually return.
C. While this oxygen saturation level of 89% while the client is sleeping is lower than ideal (usually 92% or higher), a drop in oxygen saturation can be due to the effects of anesthesia or sleep, and it may resolve with repositioning or other interventions. However, this may warrant monitoring.
D. Increasing abdominal distention is the most concerning finding and would require immediate notification of the surgeon. It could indicate a bowel obstruction, ileus, or perforation, all of which are serious complications after a bowel resection. Immediate intervention is needed to prevent further complications such as sepsis or shock.

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The nurse is assessing a client who is 24-hours post-op after creation of a descending end colostomy due to colon cancer. Which of the following is an expected finding for this client?

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Naxlex Comprehensive Predictor Exams

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Explanation

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