The nurse is providing care for a client with a bowel obstruction who had a transverse colostomy created. Which observation requires immediate notification of the primary health care provider?

Stoma is beefy red and shiny.

Purple discoloration of the stoma.

Skin excoriation around the stoma.

Semiformed stool noted in the ostomy pouch.

Answer and Explanation

The Correct Answer is B

Choice A reason: A beefy red, shiny stoma is normal, indicating healthy tissue perfusion. Purple discoloration suggests ischemia, making this incorrect, as it doesn’t require immediate notification compared to the nurse’s priority of reporting a potentially life-threatening stoma complication to the provider.

Choice B reason: Purple discoloration of the stoma indicates potential ischemia or necrosis, a serious complication requiring immediate provider notification. This aligns with colostomy care priorities, making it the correct observation for the nurse to report promptly to prevent further tissue damage or obstruction.

Choice C reason: Skin excoriation around the stoma is concerning but less urgent than purple discoloration, which signals ischemia. This is incorrect, as it can be managed with barrier creams, unlike the nurse’s priority of addressing a critical stoma issue requiring immediate intervention.

Choice D reason: Semiformed stool in the ostomy pouch is expected post-colostomy and not alarming. Purple discoloration is critical, making this incorrect, as it’s a normal finding compared to the nurse’s need to notify the provider about a potentially ischemic stoma.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Increased urine output is not typical in untreated hypothyroidism, which slows metabolism and fluid balance. Hypotension from reduced cardiac output is expected, making this incorrect, as it doesn’t align with the nurse’s anticipated findings in a client non-compliant with hypothyroidism therapy.

Choice B reason: Persistent diarrhea is more associated with hyperthyroidism, not hypothyroidism, which causes constipation. Hypotension is a common finding in untreated hypothyroidism, making this incorrect, as it contradicts the expected symptoms in the nurse’s assessment of the non-compliant client.

Choice C reason: Hypotension is expected in untreated hypothyroidism due to decreased metabolic rate and cardiac output. This aligns with endocrine assessment findings, making it the correct finding the nurse would anticipate in a client who hasn’t taken thyroid replacement medication regularly.

Choice D reason: Tachycardia is typical in hyperthyroidism, not hypothyroidism, which causes bradycardia. Hypotension is more consistent with untreated hypothyroidism, making this incorrect, as it doesn’t reflect the slowed metabolism expected in the nurse’s evaluation of the non-compliant client.

A. Assessing blood pressure. B. Measuring intake and output. C. Elevating the head of the bed. D. Checking for presence of dependent edema.

Correct Answer is C

Explanation

Choice A reason: Assessing blood pressure monitors fluid overload but doesn’t immediately reduce respiratory strain. Elevating the head of the bed improves breathing, making this incorrect, as it’s less urgent than the nurse’s first action to prevent harm from fluid overload.

Choice B reason: Measuring intake and output tracks fluid balance but is less immediate than elevating the bed to ease breathing. This is incorrect, as it delays the nurse’s priority action to alleviate respiratory distress in a client with suspected fluid overload.

Choice C reason: Elevating the head of the bed is the first action to reduce respiratory distress in fluid overload by decreasing venous return. This aligns with acute care priorities, making it the correct action to prevent harm in the client with suspected hypervolemia.

Choice D reason: Checking for dependent edema confirms fluid overload but doesn’t address immediate respiratory risks. Elevating the bed is urgent, making this incorrect, as it’s secondary to the nurse’s first action to improve breathing in the fluid-overloaded client.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is providing care for a client with a bowel obstruction who had a transverse colostomy created. Which observation requires immediate notification of the primary health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is assessing a client who requires lifelong replacement hormone therapy for hypothyroidism. The client has not been taking his medication regularly. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

Which action will the nurse perform first to prevent harm for a client suspected to have fluid overload?

Correct Answer is C

Explanation

A nurse is providing teaching to a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching?

The nurse cares for a client diagnosed with Type 1 diabetes and Raynaud’s disease. The orders include continuous pulse oximetry monitoring. Which situation requires an intervention by the nurse?

The nurse has just received a report on a group of clients on the neurosurgical unit. Which client is the nurse’s first priority?

The nurse is providing care for a client with a bowel obstruction who had a transverse colostomy created. Which observation requires immediate notification of the primary health care provider?

A client suspected of having a duodenal ulcer has undergone esophagogastroduodenoscopy. The nurse would place the highest priority on which item as part of the client’s care plan?

Which assessments are most important for the nurse to perform to prevent harm on a client with a sodium level of 118 mEq/L (mmol/L)? (Select all that apply)

The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items would the nurse include on this list? (Select all that apply)