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 D

Explanation

Choice A reason: Flushing with 15 mL water between medications is correct to prevent clogging and ensure delivery. Immediate feeding reconnection risks phenytoin absorption, making this incorrect, as it’s a proper action unlike the error requiring the nurse’s immediate intervention.

Choice B reason: Reinserting 50 mL of aspirated stomach contents is acceptable to maintain fluid balance. Reconnecting feeding immediately affects phenytoin efficacy, making this incorrect, as it’s a correct action compared to the student’s error needing the nurse’s urgent correction.

Choice C reason: Checking gastric aspirate pH confirms tube placement, a safety step. Immediate feeding reconnection reduces phenytoin absorption, making this incorrect, as it’s a proper action unlike the student’s mistake requiring the nurse’s immediate intervention for medication administration.

Choice D reason: Reconnecting enteral feeding immediately after phenytoin reduces its absorption, as feedings should be held for 1-2 hours. This requires immediate intervention, aligning with medication administration protocols, making it the correct action for the nurse to address in the student’s care.

A. Check the level of the drainage bag. B. Reposition the client to the side. C. Place the client in good body alignment. D. Check the peritoneal dialysis system for kinks. E. Contact the primary health care provider (PHCP). F. Increase the flow rate of the peritoneal dialysis solution.

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

Explanation

Choice A reason: Checking the drainage bag level ensures it’s below the abdomen to promote gravity-dependent outflow. This addresses reduced outflow in peritoneal dialysis, making it a correct action the nurse would take to resolve the inflow-outflow discrepancy safely.

Choice B reason: Repositioning to the side can dislodge catheter obstructions or improve drainage in peritoneal dialysis. This is a standard intervention for low outflow, making it a correct action the nurse would perform to correct the client’s dialysis flow issue.

Choice C reason: Good body alignment prevents catheter kinking and promotes effective drainage in peritoneal dialysis. This addresses outflow issues, making it a correct action the nurse would take to ensure proper function of the dialysis system for the client.

Choice D reason: Checking for kinks in the dialysis system identifies mechanical causes of reduced outflow. This is a key troubleshooting step, making it a correct action the nurse would perform to resolve the inflow-outflow imbalance in the client’s peritoneal dialysis.

Choice E reason: Contacting the provider is premature before troubleshooting mechanical issues like kinks or positioning. Checking the drainage bag is a priority, making this incorrect, as it delays the nurse’s initial actions to correct the dialysis outflow problem independently.

Choice F reason: Increasing the flow rate doesn’t address outflow obstruction and may worsen fluid imbalance. Repositioning is more appropriate, making this incorrect, as it’s not a safe action compared to the nurse’s focus on resolving mechanical dialysis issues first.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse monitoring a client receiving peritoneal dialysis notes that the client’s outflow is less than the inflow. Which actions would the nurse take? (Select all that apply)

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

Explanation

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)

Which actions are considered best practices for the nurse to use during the administration of parenteral potassium to a client with a serum potassium level of 1.9 mEq/L (mmol/L)? (Select all that apply)

The nurse is reviewing a client’s record and notes that the primary health care provider has documented that the client has chronic kidney disease. On review of the laboratory results, the nurse most likely would expect to note which finding?

After teaching a client with irritable bowel syndrome (IBS), a nurse assesses the client’s understanding. Which menu selection indicates that the client correctly understands the dietary teaching?

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? (Select all that apply)

The laboratory notifies the night nurse that the patient has a critical magnesium level of 1.1 mEq/L. The patient has a do-not-resuscitate order. The nurse does not inform the practitioner because of the patient’s code status. In doing so, the nurse is negligent for which action?

The nurse provides instructions to a client about measures to treat irritable bowel syndrome (IBS). Which statement by the client indicates a need for further teaching?

The nurse is caring for a client with ulcerative colitis. Which findings does the nurse determine is consistent with this diagnosis? (Select all that apply)