The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy?
The skin under the appliance looks red briefly after removing the appliance.
The stoma color is a deep red-purple.
An ascending colostomy delivers liquid feces.
The stoma extends 1/2 inch above the abdomen.
The Correct Answer is B
Choice A rationale: Redness briefly after removing the appliance might be common due to increased blood flow but does not necessarily indicate an issue.
Choice B rationale: A deep red-purple stoma color can suggest impaired blood supply to the stoma and requires immediate attention.
Choice C rationale: The consistency of output from the colostomy may vary based on the site and type of colostomy and might not necessarily be concerning.
Choice D rationale: The length of the stoma can vary and usually depends on the type of colostomy, and 1/2 inch above the abdomen is within an acceptable range.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: An increase in serum lipid levels is associated with nephrotic syndrome, not recovery.
Choice B rationale: A decrease in blood pressure to normal might be beneficial but is not a definitive indicator of recovery from nephrotic syndrome.
Choice C rationale: Gain in body weight can occur due to fluid retention, which is a symptom of nephrotic syndrome, and doesn't indicate recovery.
Choice D rationale: The disappearance of protein from the urine is a sign of recovery in nephrotic syndrome.
Correct Answer is A
Explanation
Choice A rationale: Arterial blood gas (ABG) findings provide direct information about oxygenation and acid-base balance in the blood, which can indicate hypoxemia and metabolic acidosis.
Choice B rationale: Oxygen saturation level provides information about oxygen saturation in the blood but doesn't give a complete assessment of acid-base balance or other gases in the blood.
Choice C rationale: White blood cell differential assesses different types of white blood cells and is not directly related to evaluating hypoxemia or metabolic acidosis.
Choice D rationale: Red blood cells (RBCs) and hemoglobin count findings are important but do not directly assess hypoxemia or metabolic acidosis.
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