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 D

Explanation

Choice A reason:

Avoiding chemicals that are toxic to the liver is a valid recommendation for liver health, but it is not specific to preventing hepatitis E virus infection.

Choice B reason:

Limiting alcohol intake is an important measure for maintaining liver health, but it is not a specific prevention measure for hepatitis E virus.

Choice C reason:

Wearing a condom during sexual contact is an important measure to prevent the transmission of certain sexually transmitted infections (STIs), but hepatitis E is primarily transmitted through contaminated water and not through sexual contact.

Choice D reason:

Following proper hand-washing techniques is a crucial preventive measure for hepatitis E virus. This virus is primarily transmitted through the fecal-oral route, often via contaminated water or food. Proper hand hygiene can significantly reduce the risk of transmission.

A. Keep the patient in a low Fowler's position when at rest. B. Connect the tube to continuous wall suction when not in use. C. Confirm placement of the tube prior to each medication administration. D. Have the patient sip cool water to stimulate saliva production.

Correct Answer is C

Explanation

Choice A reason:

Keeping the patient in a low Fowler's position may be helpful for some patients with dysphagia, but it is not a specific intervention related to NG tube care.

Choice B reason:

Connecting the tube to continuous wall suction when not in use is not a standard practice for NG tube care. Continuous suction can cause mucosal damage and discomfort for the patient.

Choice C reason:

Confirming the placement of the NG tube prior to each medication administration is a crucial safety measure. Incorrect placement can lead to serious complications.

Choice D reason:

Sipping cool water to stimulate saliva production may be beneficial for some patients with dysphagia, but it is not a specific intervention related to NG tube care. The focus should be on confirming the placement of the tube.

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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

During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus?

Correct Answer is D

Explanation

A patient's new onset of dysphagia has required insertion of an NG tube for feeding; the nurse has modified the patient's care plan accordingly. What intervention should the nurse include in the patient's plan of care?

Correct Answer is C

Explanation

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