The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which assessment finding immediately?

Stoma is purple

Stoma is moist.

Stoma is flush with the skin

Stoma is protruding from the abdomen

Answer and Explanation

The Correct Answer is A

A. Stoma is purple. A purple, dusky, or black stoma indicates poor blood circulation, possibly due to ischemia or necrosis. This is a surgical emergency requiring immediate attention.

B. Stoma is moist. Normal finding, indicating adequate perfusion.

C. Stoma is flush with the skin. Possible but not necessarily abnormal. However, a retracted stoma (sunken below skin level) could lead to leakage and skin irritation.

D. Stoma is protruding from the abdomen. Normal in the early postoperative period. A slight protrusion (bud-like shape) is expected. However, significant prolapse (excessive protrusion) may need evaluation.

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Correct Answer is D

Explanation

A. RBC 4.9 mm³: Chronic glomerulonephritis often leads to anemia due to decreased erythropoietin production, so a normal RBC count is unexpected.

B. Serum potassium 4.0 mEq/L : Kidney disease often leads to hyperkalemia (K⁺ >5.0 mEq/L) due to impaired potassium excretion.

C. Serum creatinine 0.8 mg/Dl: Chronic kidney disease results in increased creatinine levels (>1.3 mg/dL) due to reduced glomerular filtration.

D. BUN 100 mg/dL: BUN (Blood Urea Nitrogen) is elevated in kidney dysfunction. Normal BUN is 6–20 mg/dL, and a BUN of 100 mg/dL suggests severe renal impairment.

A. Urine output of 80 mL/hr B. Specific gravity of 1.036 C. pH of 6.4 D. Protein level of 2 mg/100 mL

Correct Answer is B

Explanation

A. Urine output of 80 mL/hr: Normal urine output is 30–50 mL/hr. A urine output of 80 mL/hr is within an acceptable range and does not indicate a problem.

B. Specific gravity of 1.036: Normal urine specific gravity ranges from 1.005 to 1.030. A level of 1.036 indicates dehydration or concentrated urine, which requires further assessment.

C. pH of 6.4: Normal urine pH ranges from 4.5 to 8.0, with an average around 6.0. A pH of 6.4 is within normal limits and does not require follow-up.

D. Protein level of 2 mg/100 mL: Normal urine protein is less than 8 mg/100 mL, so 2 mg/100 mL is within normal limits and does not indicate a concern.

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The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which assessment finding immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory values of a client who has chronic glomerulonephritis. Which of the following is an expected finding for this client?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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