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.

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Correct Answer is A

Explanation

Choice A reason: Distended neck veins in the sitting position indicate worsening hypervolemia, reflecting increased venous pressure and heart strain. This aligns with cardiovascular assessment, making it the correct finding the nurse would identify as a sign of deteriorating fluid overload in the client.

Choice B reason: Breath sounds in the right lower lobe are normal unless crackles indicate fluid. Distended neck veins are more specific to worsening hypervolemia, making this incorrect, as it’s not a clear sign of deterioration in the nurse’s fluid status assessment.

Choice C reason: Unchanged weight doesn’t indicate worsening hypervolemia, which causes weight gain. Distended neck veins signal increased fluid, making this incorrect, as it’s not a dynamic finding compared to the nurse’s assessment of worsening fluid overload in the client.

Choice D reason: Yellow-tinged nose and ears suggest jaundice, not hypervolemia. Distended neck veins are a direct sign of worsening fluid status, making this incorrect, as it’s unrelated to the nurse’s evaluation of deteriorating hypervolemia in the client’s condition.

A. Ask the client to rate the location and severity of pain at the insertion site. B. Assess bilateral dorsalis pedis and posterior tibial pulses. C. Observe the catheter access site. D. Check bilateral lower extremity capillary refill time.

Correct Answer is B

Explanation

Choice A reason: Assessing pain at the insertion site is important but less urgent than ensuring vascular patency post-catheterization. Checking pulses detects complications like occlusion, making this incorrect, as it’s secondary to the nurse’s priority of monitoring for vascular issues immediately post-procedure.

Choice B reason: Assessing dorsalis pedis and posterior tibial pulses is most important to detect vascular complications, such as arterial occlusion, post-cardiac catheterization. This aligns with post-procedure protocols, making it the correct action to ensure limb perfusion and prevent serious complications immediately.

Choice C reason: Observing the access site for bleeding is key but secondary to ensuring distal perfusion via pulses. Vascular occlusion is a greater risk, making this incorrect, as it’s less urgent than the nurse’s priority of checking pulses post-cardiac catheterization.

Choice D reason: Checking capillary refill time assesses perfusion but is less specific than pulse assessment for detecting arterial issues post-catheterization. Pulses are the priority, making this incorrect, as it’s secondary to the nurse’s focus on immediate vascular integrity post-procedure.

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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

Which assessment finding on a client with hypervolemia indicates to the nurse that the client’s condition may be worsening?

Correct Answer is A

Explanation

A client returns to the unit immediately following a cardiac catheterization. Which action by the nurse is MOST important?

Correct Answer is B

Explanation

The client newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse would assess the client during dialysis for which associated manifestations?

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