A patient with a newly created colostomy becomes pale and weak. The stoma is dusky, cool, and no longer produces output. What should the nurse do first?
Correct answer: A. Assess the patient promptly and notify the surgical team
- A. Assess the patient promptly and notify the surgical team
- B. Apply a warm compress directly over the stoma
- C. Insert a cotton swab into the stoma to check its depth
- D. Wait until the next scheduled dressing change to reassess it
Explanation
A dusky, cool stoma with absent output may indicate impaired blood supply or obstruction. Prompt assessment and surgical review are needed because stoma compromise can progress rapidly; the stoma should not be probed or heated.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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