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Practice Question

A client returns from surgery with a colostomy. When assessing the stoma of the new colostomy, which sign and symptom indicates further intervention is needed?

Answer Choices:

Correct Answer:

The stoma is dry and intact and light brown in color.

Rationale:

🩺A healthy, viable stoma should be moist, shiny, and pink-to-red, indicating adequate perfusion; a dry, light brown/dusky stoma suggests ischemia.

🩺Tissue hypoperfusion can rapidly progress to necrosis, placing the client at risk for infection, dehiscence, and systemic complications.

🩺Early recognition and emergent notification of the surgeon are essential to restore blood flow and preserve stoma viability.

🩺Ongoing monitoring should include color, moisture, turgor, bleeding, and output to trend perfusion status.

🩺Prompt intervention aligns with postoperative stoma standards, protecting patient safety and surgical outcomes.

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This question is from EXAM #4 UPPER AND LOWER GI FALL 25 CLARK STATE COMMUNITY COLLEGE which contains 47 questions.

More Questions from This Exam
What information is important to teach a client concerning how they can prevent constipation?

Answer Choices:

A. Enemas, increased fluid intake, and exercise.
B. Exercise, increased fluid intake and high fiber diet.
C. Laxatives, increased fluid intake and low fiber diet.
D. Stool softners, low fiber diet and increased fluid intake.
A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?

Answer Choices:

A. Mix the three medications together prior to administering.
B. Dilute each medication with 30 mls of water.
C. Maintain the head of the bed in a flat position for 30 min following medication administration.
D. Flush the NG tube with 30 mL water immediately after giving the medications.
The nurse is caring for a client who has a percutaneous endoscopic gastrostomy (PEG) tube. Which of the following is an appropriate nursing action prior to administering the client's medication?

Answer Choices:

A. Warm the feeding solution to body temperature.
B. Place the patient in Simm's position.
C. Aspirate stomach contents and confirm that the stomach contents is above ph of 5.
D. Check that residual gastric contents is under 150 ml.
A client with abdominal distention has an NG tube hooked to low gastric suction. The client is reporting anxiety, nausea, discomfort and a feeling of bloating. Which of the following is the nurse's priority action?

Answer Choices:

A. Request a prescription for some medication to ease the client's anxiety.
B. Irrigate the nasogastric tube with 100ML of sterile water.
C. Check to see if the suction equipment is working.
D. Remove and reinsert the nasogastric tube.
From Exam
EXAM #4 UPPER AND LOWER GI FALL 25 CLARK STATE COMMUNITY COLLEGE

47 Questions

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Question Details
  • Category: RN Nursing Exam(s)
  • Subcategory: General Exams
  • Domain: Medical-surgical📚
  • Answer Choices: 4
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