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 ["B","C","D"]

Explanation

Choice A reason: Testing skin turgor assesses dehydration, not severe hyponatremia (118 mEq/L), which affects neurological status. Assessing cognition detects complications, making this incorrect, as it’s less critical than the nurse’s priority of monitoring for hyponatremia’s neurological and fluid effects.

Choice B reason: Assessing cognition is critical with a sodium level of 118 mEq/L, as severe hyponatremia causes confusion or seizures. This aligns with neurological assessment, making it a correct action the nurse should perform to prevent harm in the hyponatremic client.

Choice C reason: Monitoring urine output tracks fluid balance, vital in hyponatremia to assess for SIADH or fluid overload. This aligns with renal assessment, making it a correct action the nurse should perform to prevent harm in the client with severe hyponatremia.

Choice D reason: Checking deep tendon reflexes detects neurological changes from hyponatremia, such as hyporeflexia or seizures. This aligns with neurological monitoring, making it a correct assessment the nurse should perform to prevent harm in the client with a sodium of 118 mEq/L.

Choice E reason: Abdominal pain is unrelated to hyponatremia, which primarily affects the brain and fluid balance. Monitoring urine output is more relevant, making this incorrect, as it’s not a priority assessment for the nurse to prevent harm in the hyponatremic client.

Choice F reason: Fever may indicate infection but isn’t directly linked to hyponatremia’s neurological risks. Assessing cognition is critical, making this incorrect, as it’s less urgent than the nurse’s focus on preventing harm from severe hyponatremia’s neurological complications.

A. Antibiotic therapy. B. Peritoneal dialysis. C. Removal of the transplanted kidney. D. Increased immunosuppression therapy.

Correct Answer is D

Explanation

Choice A reason: Antibiotics treat infection, but fever, tenderness, and rising creatinine suggest rejection, not infection. Immunosuppression addresses rejection, making this incorrect, as it’s less likely than the nurse’s anticipation of therapy to manage transplant rejection in the client.

Choice B reason: Peritoneal dialysis is used for kidney failure, not acute transplant rejection, which causes fever and creatinine rise. Immunosuppression is needed, making this incorrect, as it’s irrelevant to the nurse’s expected treatment for the client’s post-transplant symptoms.

Choice C reason: Removing the kidney is a last resort, not the first response to rejection signs like fever and tenderness. Increased immunosuppression is standard, making this incorrect, as it’s premature compared to the nurse’s anticipation of rejection management.

Choice D reason: Increased immunosuppression treats acute transplant rejection, indicated by fever, tenderness, rising creatinine, and kidney enlargement. This aligns with post-transplant care, making it the correct treatment the nurse would anticipate for the client’s symptoms one week after transplantation.

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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 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)

Correct Answer is ["B","C","D"]

Explanation

Correct Answer is D

Explanation

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