Question: On the first postoperative day the nurse assesses a client's colostomy stoma and notes that it is moist and dark pink with no obvious drainage. Which action should the nurse consider taking?
1. Document the normal findings.
2. Consult the enterostomal therapist.
3. Irrigate the ostomy with normal saline.
4. Palpate the abdomen around the stoma.
Rationale: A colostomy stoma that is moist and dark pink without any drainage on the first postoperative day has a normal appearance. These findings should be documented in the client's medical record. The items in the other answer options (2, 3, 4) are not necessary because the assessment of the colostomy stoma is normal.
Cognitive Level: Application
Nursing Process: Assessment
NCLEX Test Plan Category: Physiological Integrity
This week’s NCLEX exam practice question came from:
Manno: Mosby's Review Cards for the NCLEX-RN Examination, 3rd Edition, Section 7, pg 535, question 124
No comments:
Post a Comment