Question

1. The nurse is caring for a client who is postoperative day 3 following a total colectomy and secretion of an ileostomy. While changing the dressing the nurse notes the ileostomy stoma is dusky in color. How should the nurse interpret this assessment finding? - The client o2 saturation below, - The stoma is blocked. - Circulation to the stoma a compromised - This is a normal assessment finding postoperatively

2. During the first 15 minutes of the transfusion the client complains of chills the nurse understands chills are an indication that the client? - Is having the onset of a seizure - Is having a transfusion reaction - Is having a normal reaction to the blood - Has caught a cold

Answer 1

Q.N.1

The right answer is circulation to the stoma is compromised

Usually, following the, surgery the normal colour of the stoma will remain pink or red for atleast first week, then slowly the colour will change.Hence the stoma needs to remain pink following the surgery.If the stoma is blocked due to any resons, there will be foul discharge and absence of contents from the stoma develops.And the clients may have a enlarged abdomen, nausea etc. When the circulation to the stoma is compramised due to any edema, the colour of the stoma will change to blue or dusky fron red or pink. Husky colour is not a normal finding post operatively.Hece all other options can be excluded here.

Q.N.2

The right answer here is the client is having a transfusion reaction.

Blood transfusion, is the transfusion of whole blood or other blood components like RBC, plasma, WBC , clotting factors etc are administred to a individual. During the transfusion, the nurse has to constantly monitor the patient for any transfusion reaction or any allergic reaction to the components tranfused. The allergic reactions and transfusion reactions are usually manifested as chills, shivering, rashes, incresed body temperature, tachycardia, breathing difficulties etc.Which indicate that the client is developing allergies to the blood or blood products. These symptoms usually develop within first 15 minutes of administration. So the nurse need to be with the patient and check his vitals every 15 minutes in the first hour of blood transfusion.If any such transfusion reactions develops, the immediate responsibility of the nurse is to stop the transfusion and report to the physician. Here the other options can be excluded, because it is not a normal reaction,And this is not the response of cold. Seizures are usually manifested with aura stage and the client can even report that.The seizure activity is associated with rhythemic tonic clonic movements. Hence all other options can be excluded here.