The nurse is monitoring for stoma prolapse in a client with a colostomy. Which stoma observation should indicate that a prolapse has occurred?
The stoma is moist and shiny
The stoma is pink or red in color
The stoma is flat and sunken
The stoma is swollen and protruding
The Correct Answer is D
Rationale:
A. A moist, shiny appearance is normal and healthy for a stoma. This indicates that the mucosal tissue is well-hydrated and functioning properly. While it is an important observation, it does not indicate prolapse or any pathological change.
B. A pink or red stoma signifies good blood flow and is considered healthy. Color changes are critical to monitor for ischemia (pale, dusky, or dark blue) or necrosis, but simply being pink or red does not indicate prolapse.
C. A flat or sunken stoma indicates retraction, which is the opposite of prolapse. Retraction occurs when the stoma sinks below skin level, often due to muscle tension, obesity, or surgical technique. While retraction can cause appliance-fitting problems and leakage, it is not a protruding prolapse.
D. A prolapsed stoma occurs when the bowel telescopes outward through the stoma, appearing longer than usual, swollen, and protruding. This can impair blood flow, cause edema, and make appliance fitting difficult. Prompt recognition and reporting are essential to prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Rationale:
A. Stabilization from the abdominal rectus is correct because placing the stoma through the rectus abdominis muscle helps reduce the risk of herniation and provides better support for the stoma.
B. Good seal is correct because proper stoma placement allows the ostomy appliance to adhere securely, reducing leakage and protecting the surrounding skin.
C. Proximity to the umbilicus (not too close to area) is correct because the stoma should not be placed too close to the umbilicus, scars, or skin folds, which can interfere with appliance fit and increase leakage risk.
D. Ease of self-care is correct because the stoma should be located where the client can easily see and reach it, promoting independence in ostomy care.
E. Inoffensive appearance is incorrect because cosmetic appearance is not a priority in determining stoma placement. Function, safety, and the client’s ability to manage the stoma take precedence.
Correct Answer is B
Explanation
Rationale:
A. Mucus in the urine is expected in patients with an ileal conduit because the urinary diversion uses a segment of the ileum, which naturally secretes mucus. This is not an immediate concern.
B. Abdominal distention in an immediate postoperative patient may indicate bowel obstruction, ileus, or internal bleeding. These conditions can become life-threatening if not addressed promptly, so the nurse should report and intervene immediately.
C. A small amount of blood in the urine or drainage is expected in the early postoperative period due to surgical manipulation of the ureters and ileum. It is monitored but not an emergency.
D. Absent bowel sounds are common immediately after abdominal surgery due to temporary postoperative ileus. While it should be monitored, it is not immediately life-threatening unless accompanied by severe pain, distention, or vomiting.
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