Question 1

When assessing the colour of a new stoma in the postoperative period, which of the following findings should cause the nurse to suspect anemia?

Accepted Answer

A pale pink stoma indicates anemia. A light red rose or dark red brick colour indicates a viable stoma mucosa. A blanching dark red to purple stoma may indicate inadequate blood supply to the stoma, low flow state, excessive tension on the bowel mesentery at the time of construction, or venous congestion; usually occurs in the first 72 hour after surgery.

Question 2

After receiving change-of-shift report, which of the following clients should the nurse assess first?

Accepted Answer

The client's abdominal distension and tachycardia suggest hypovolemic shock caused by problems such as peritonitis or intestinal obstruction, which will require rapid intervention. The other clients also should be assessed as quickly as possible, but the data do not indicate any life-threatening complications associated with their diagnoses.

Question 3

The nurse is caring for a client who has been taking antibiotics for several days and develops watery diarrhea. Which of the following actions should the nurse take first?

Accepted Answer

The client's history and new onset diarrhea suggest a C. difficile infection, which requires implementation of contact precautions to prevent spread of the infection to other clients. The other actions also are appropriate but can be accomplished after contact precautions are implemented.

Question 4

The nurse is assessing a client with colorectal cancer. Which of the following symptoms should the nurse expect to assess? (Select all that apply.)

Accepted Answer

The symptoms of colorectal cancer include early satiety and rectal bleeding, including other signs and symptoms. The client would experience weight loss, not gain. Right shoulder pain is not a symptom of colorectal cancer but abdominal and low back pain are often seen. Clients with colorectal cancer have increased flatus, not decrease flatus.

Question 5

The nurse is interviewing a 40-year-old client and obtains information about the following client problems. Which of the following information is most important to communicate to the health care provider?

Accepted Answer

Blood in the stools is a possible clinical manifestation of colorectal cancer and requires further testing by the health care provider. The other client information also will be communicated to the health care provider, but does not indicate an urgent need for further testing or intervention.

Question 6

A client with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as illustrated. Which of the following information should the nurse include in client teaching?

Accepted Answer

A loop, or double-barrel stoma, is usually temporary. Stool will be expelled from the proximal stoma only. The stool from the transverse colon will be liquid and regulation through irrigations will not be possible.

Quiz 45: Nursing Management Lower Gastro-intestinal Problems