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 A
Explanation
Choice A rationale: This is a condition that causes scar tissue to form in the penis, resulting in abnormal curvature, pain, and erectile dysfunction.
Choice B rationale: Hypospadias is a congenital defect in which the opening of the urethra is on the underside of the penis, not at the tip.
Choice C rationale: Phimosis is a condition in which the foreskin of the penis cannot be retracted fully, leading to inflammation and infection.
Choice D rationale: Orchitis is an inflammation of one or both testicles, usually caused by an infection.
Correct Answer is B
Explanation
Choice A rationale: A calcium level of 8.6 mg/dL is within the normal range.
Choice B rationale: An elevated white blood cell count (WBC) of 19,000 mm3 indicates a potential infection or inflammatory process, requiring immediate attention, especially in a client receiving peritoneal dialysis.
Choice C rationale: A serum pH of 7.33 is within the normal range.
Choice D rationale: A hemoglobin level of 9 mg/dL might indicate anemia, but in a client receiving dialysis, it might not require immediate reporting unless it significantly drops further.
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