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 B

Explanation

A. A female client who has a body mass index of 24: A BMI of 18.5–24.9 is considered normal weight. Since the BMI is 24, this client is in the normal weight range.

B. A male client who has a body mass index of 29: A BMI of 25–29.9 is classified as overweight. Since the BMI is 29, this client is overweight but not obese.

C. A male client who has a waist circumference of 96.52 cm (38 in): The at-risk waist circumference for males is ≥40 inches (102 cm). Since this client’s waist circumference is 38 inches, he is not classified as overweight based on this parameter.

D. A female client who has a waist circumference of 101.6 cm (40 in): The at-risk waist circumference for females is ≥35 inches (88 cm), but waist circumference alone does not classify someone as overweight. BMI is the primary measure used.

A. "You should limit fluids in the evening." B. "Your provider might prescribe anticholinergic medications." C. "You might require an anterior vaginal repair" D. "You should restrict your intake of caffeine E. "You might require intermittent urinary catheterization."

Correct Answer is ["A","B","D"]

Explanation

A. "You should limit fluids in the evening." Helps reduce nighttime urinary urgency.

B. "Your provider might prescribe anticholinergic medications." Anticholinergics like oxybutynin reduce bladder contractions, decreasing urgency.

C. "You might require an anterior vaginal repair." More commonly done for stress incontinence, not urge incontinence.

D. "You should restrict your intake of caffeine." Caffeine is a bladder irritant and increases urinary urgency.

E. "You might require intermittent urinary catheterization." Not necessary unless the client has urinary retention, which is not typical for urge incontinence.

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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

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Correct Answer is ["A","B","D"]

Explanation

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