Basic Physical Assessment

A nurse is helping to plan a teaching session for a client who will be discharged with a colostomy. Which statement describes a healthy stoma? a) "The stoma should remain swollen distal to the abdomen." b) "At first, the stoma may bleed slightly when touched." c) "A burning sensation under the stoma faceplate is normal." d) "The stoma should appear dark and have a bluish hue." - Answer- B. "At first, the stoma may bleed slightly when touched." Explanation: The surgical site remains fresh for up to 1 week after a colostomy and touching the stoma normally causes slight bleeding. However, profuse bleeding should be reported immediately. A dark stoma with a bluish hue indicates impaired circulation; a normal stoma should appear red, similar to the buccal mucosa. Swelling should decrease in 6 weeks, leaving a stoma that protrudes slightly from the abdomen; continued swelling suggests a blockage. A burning sensation under the faceplate is abnormal and indicates skin breakdown. On the second day after surgery, the nurse assesses an elderly client and finds the following: • BP 148/92, HR 98, RR 32 • O2 saturation of 88 on 4 L/min of oxygen administered by nasal cannula • Breath sounds coarse and wet bilaterally with a loose, productive cough • Client voided 100 ml very dark, concentrated urine during the last 4 hours • Bilateral pitting pedal edema Using the SBAR method to notify the health care provider of current assessment findings, which of the following is the most appropriate recommendation? a) Encourage additional fluid intake. b) Increase oxygen liter flow rate. c) Administer an antihypertensive medication. d) Administer a diuretic medication. - Answer- D. Administer a diuretic medication. Explanation: The client is experiencing fluid overload and has vital signs outside normal limits. The provider must be notified of the client's current status. It would be appropriate to recommend that the provider administer a diuretic to correct the fluid overload. It is not appropriate to administer an antihypertensive medication or more fluids. It may be appropriate to administer additional oxygen, but because of the fluid volume excess the client exhibits, diuretic administration is most important.