Safe, Effective Care Environment
55. A client has a colostomy following surgery for colon cancer. Which assessment finding would require immediate action by a nurse?
Safe, Effective Care Environment
55. A client has a colostomy following surgery for colon cancer. Which assessment finding would require immediate action by a nurse?
. Stoma is raised 2 cm from the abdominal wall.
. Bleeding was noted from the stoma during care.
. Complaint of pain with light touch.
. Stoma was pinkish-red in color.
Test-Taking Tip
Pain is not normal and indicates a problem for any client situation.
Content Area: Adult Health, Gastrointestinal; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Safe and Effective Care Environment/Management of Care/Establishing Priorities
Safe, Effective Care Environment
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Answer 1 is incorrect because the stoma will be 1 to 2 cm above the skin. Because the stoma is swollen after surgery, the size will change. Answer 2 is incorrect because some bleeding is normal. If it bleeds too often, the physician should be notified. Answer 3 is correct because, since there are no nerves in the mucous membranes, there should be no pain when touching. Pain would possibly indicate a problem internally. Answer 4 is incorrect because this is a normal appearance. If the stoma becomes dusky in color, this could need immediate action.