HESI RN Med surg proctored exam 2
The nurse assesses an adult client 24 hours after a bowel exploration and formation of a sigmoid colostomy. Which assessment finding should be reported to the surgeon immediately?
Explanation & Rationale
Choice A reason: Absence of bowel sounds can be expected postoperatively and is not as urgent as other signs.Choice B reason:The correct answer is b) because a purple stoma mucosa indicates compromised blood flow to the stoma, which requires immediate surgical intervention to prevent tissue necrosis.Choice C reason: Streaks of bright red blood in the stoma are not unusual shortly after surgery and are not an immediate cause for alarm.Choice D reason: Brown fecal matter with a solid consistency is a normal finding post-colostomy and does not need to be reported immediately.
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