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. Applying ice packs to the radiated area is not typically recommended, as it can cause additional skin irritation or damage. Skin care after radiation usually focuses on keeping the skin moisturized and protected.
B. Wear loose soft clothing over the treated area is the most important instruction because radiation therapy can cause skin irritation and sensitivity. Wearing loose, soft clothing helps to avoid further friction or irritation on the sensitive skin in the treated area.
C. Avoiding sharing bathrooms or toilets with others for 48 hours after treatment is not a required precaution for external radiation therapy, as there is no significant risk of radiation exposure to others through contact with shared bathroom facilities. This is more applicable to certain types of radioactive implants or internal radiation therapies.
D. While rest is important during cancer treatment, this instruction is more general and not as specific to skin care management during radiation therapy. The primary focus for skin care would be preventing irritation and damage to the skin in the radiated area.

A. monitoring for dysrhythmias. B. preventing thrombus formation. C. monitoring for bleeding D. adherence to the antihypertensive drugs

Correct Answer is D

Explanation

A. While monitoring for dysrhythmias is important for certain cardiovascular conditions, it is not the primary concern for an AAA. The management of blood pressure and preventing rupture are higher priorities.

B. While blood clots can be a concern in some cardiovascular conditions, thrombus formation is not a primary concern with AAA management unless other risk factors (such as venous stasis or atrial fibrillation) are present.

C. Monitoring for bleeding would be more relevant if the aneurysm were large or there were signs of rupture, but for a small AAA, the primary concern is managing blood pressure and preventing further enlargement. Bleeding monitoring is more critical in cases of rupture or larger aneurysms.

D. Antihypertensive medications are crucial for controlling blood pressure and preventing further stress on the aneurysm. Adherence to these medications is essential in managing the condition medically to reduce the risk of rupture or further enlargement of the aneurysm.

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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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Correct Answer is D

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