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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?

A.

Stoma is purple

B.

Stoma is moist.

C.

Stoma is flush with the skin

D.

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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Related Questions

Correct Answer is A

Explanation

A. Urine output of 175 mL in the past 8 hours. Urine output <30 mL/hr (less than 240 mL in 8 hours) indicates oliguria, a sign of worsening renal function or acute kidney injury (AKI).

B. Urine is cloudy after sitting in the urinal for 6 hours. Urine naturally becomes cloudy when it sits due to precipitation of solutes.

C. First-voided urine in the morning has a strong odor. Morning urine is more concentrated, causing a strong odor.

D. Urine output of 2,200 mL in the past 24 hours. Not necessarily concerning unless the client has polyuria (>3L/day), which can indicate diabetes or diuretic effects, but 2,200 mL is still within the normal range.

Correct Answer is A

Explanation

A. Report a positive finding to the provider. A positive guaiac test indicates the presence of blood in the stool, which may suggest gastrointestinal bleeding, colorectal cancer, or other GI disorders. It must be reported for further evaluation.

B. Don sterile disposable gloves. Sterile gloves are not required. Clean gloves are sufficient because this is a non-sterile procedure.

C. Test the quality control section before testing the stool specimen. There is no quality control section on a fecal occult blood test. The test involves applying stool to a guaiac card and adding developer.

D. Apply liberal amounts of stool to the guaiac paper. Only a thin smear of stool is required; too much stool may interfere with accurate test results.

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