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

Answer and Explanation

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.

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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.

A. "The only time I flush my tube is when I'm putting in medications." B. "I clean my stoma twice a day with alcohol." C. "I try to stay still most of the time to avoid dislodging my tube." D. "I flush my tube with water before and after each of my medications."

Correct Answer is D

Explanation

Choice A reason:

Flushing the tube only when administering medications is not sufficient for proper maintenance. Regular flushing with water helps prevent clogs and ensures tube patency.

Choice B reason:

Cleaning the stoma with alcohol is not necessary and can be irritating to the skin. Mild soap and water are typically recommended for stoma care.

Choice C reason:

While being cautious to avoid dislodging the tube is important, it is not the primary indicator of correct tube management. Proper flushing and care are essential components of tube

maintenance.

Choice D reason:

Flushing the tube with water before and after each medication administration is a crucial step in maintaining tube patency and preventing clogs. This indicates that the patient is managing the

tube correctly.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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