Author Question: The nurse is caring for a patient who had a colostomy placed 5 days earlier. The nurse notes that ... (Read 102 times)

NguyenJ · **on:** Jun 25, 2018

The nurse is caring for a patient who had a colostomy placed 5 days earlier. The nurse notes that the stoma is red and moist. Which action should the nurse take?

a. Notify the physician immediately.
b. Apply pressure.
c. Note the condition of the stoma in her notes.
d. Change the appliance pouch.

Question 2

In caring for a patient who has an abdominal binder, it is expected that the nurse will do which of the following? (Select all that apply.)

a. Remove the binder and assess the skin and wound every 8 hours.
b. Evaluate the patient's ability to breathe deeply and cough effectively every 4 hours.
c. Evaluate the patient's pulmonary function every 8 hours.
d. Remove the binder at least daily.

pocatato · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

C
The stoma should be red or pink and moist. After assessment the nurse will note the appearance of the stoma in the patient HER. If it is gray, purple, or black, report this to the charge nurse or physician immediately. Pressure is applied to control active bleeding. The information given in the question does not indicate that there is a need to change the appliance at this time.

Answer to Question 2

A, B
Remove the binder and surgical dressing to assess the skin and wound characteristics every 8 hours to determine that the binder has not resulted in complications (e.g., rubbing or abrasion of skin, disruption of wound). Evaluate the patient's ability to ventilate properly, including deep breathing and coughing, every 4 hours to help identify any impaired ventilation. A properly applied binder will have no impact on pulmonary function.