A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?
Shiny, moist stoma
Rosebud-like stoma orifice
Purplish-colored stoma
Stoma oozing red drainage
The Correct Answer is C
Choice A reason:
A shiny, moist stoma is generally a healthy sign, indicating good blood supply and adequate hydration of the stoma tissue. It is not a cause for concern.
Choice B reason:
A rosebud-like stoma orifice is a normal appearance for some types of stomas. It indicates a healthy stoma with good blood supply. This finding is expected and does not warrant concern.
Choice C reason:
A purplish-colored stoma may indicate compromised blood supply to the stoma, which is a serious concern and should be reported to the provider promptly. It may suggest inadequate blood flow to the stoma, which could lead to tissue necrosis.
Choice D reason:
Stoma oozing red drainage may be normal immediately postoperatively. It can be due to some oozing from the surgical site, and if it's minimal and stops after a short while, it's generally not a cause for concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
In older adults, gastric motility tends to decrease rather than increase.
Choice B reason:
The gag reflex may diminish with age, making older adults more prone to swallowing difficulties.
Choice C reason:
This statement is correct. With aging, there is a decrease in mucus secretion in the gastrointestinal tract, which can lead to dryness and potential discomfort.
Choice D reason:
Gastric pH tends to increase with age, which can affect the digestion and absorption of certain nutrients.
Correct Answer is B
Explanation
Choice A reason:
Blood in the urine (hematuria) is not typically associated with cirrhosis. It may be related to other underlying conditions.
Choice B reason:
Spider angiomas (also known as spider nevi) are expected findings in clients with cirrhosis.
They are small, dilated blood vessels near the surface of the skin that resemble a spider's web. They can be found on the face, neck, upper trunk, and arms.
Choice C reason:
Tarry stools (melena) can occur in individuals with gastrointestinal bleeding, which can be a complication of cirrhosis. However, it is not a specific finding for cirrhosis itself.
Choice D reason:
Moist skin is not a characteristic finding associated with cirrhosis. It may be related to other factors such as environmental humidity or individual factors like sweating.
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