What is very important to note on a client's new stoma in the immediate postoperative period?
a. blood c. shape
b. color d. size
B
On return from surgery, the new stoma is edematous and ranges from deep red to dusky in color. The color of the stoma is checked with a penlight and documented at least once per shift. Color is important because it reveals the status of the blood supply to the stoma. If blood supply to the stoma is inadequate, the stoma will turn black. Notify the physician if the stoma darkens or becomes black. Immediately after surgery there may be a small amount of serosanguineous drainage in the appliance, the stool-collection device. When the appliance is changed and the stoma is cleaned or touched when swollen, a small amount of bleeding may occur. Reassure the client that a small amount of bleeding is normal. Bowel function is checked every shift to monitor for any obstruction or ileus. Bowel sounds, distention, and abdominal tenderness are checked every 4 hours.
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The nurse is administering a cleansing enema. Which action would indicate the need for further instruction on the process?
1. Enema solution is warmed to 40 °C (105 °F). 2. The solution container is held 12 inches above the rectum. 3. 1,000 mL of fluid is administered over 30 minutes. 4. The client is encouraged to retain the enema for 5-10 minutes.
When teaching a client about peritoneal dialysis, the nurse should stress:
a. eating a meal before each session b. having family members or friends available for assistance c. staying in bed for the duration of the procedure d. strict aseptic care of the catheter site
____________________, a synthetic opiate, has been the therapy of choice for heroin addiction. It crosses the placenta, leading to significant neonatal abstinence syndrome after birth
Fill in the blank(s) with correct word
A nurse is assessing a client who is a potential candidate for carpal tunnel release. What
factor is used to determine a client's suitability for ambulatory surgery? A) Previous surgery B) Insurance policy C) Underlying disorder D) First language