A. On the second day following an abdominoperineal resection, the nurse anticipates that the colostomy stoma will appear:
1. Dry, pale pink, and flush with the skin
2. Moist, red and raised above the skin surface
3. Dry, purple, and depressed below the skin surface
4. Moist, pink, flush with the skin, and painful when touched
B. A client returns from surgery with a permanent colostomy. During the first 24 hours the colostomy does not drain. The nurse should realize this is a result of:
1. Intestinal edema following surgery
2. A presurgical decrease in fluid intake
3. The absence of gastrointestinal motility
4. Proper functioning of nasogastric suction
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Answers
A2-the surface of a stoma is mucous membrane and should be dark pink to red, moist, and shiny; the stoma is usually raised beyond the skin surface
B3-This is caused by the trauma of intestinal manipulation and the depressive effects of anesthetics and analgesics
If you want the rationale on the other choices, let me know.
These are from Mosby's Review Questions for the NCLEX-RN
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