A nurse in a Post Anesthesia Care Unit (PACU) is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?
Rose budlike stoma orifice
Stoma oozing red drainage
Shiny, moist stoma
Purplish colored stoma
The Correct Answer is D
Choice A reason: A rosebud like stoma orifice is a normal appearance for a new colostomy, indicating that the stoma is healthy and not in distress.
Choice B reason: Red drainage from a stoma can be normal, especially in the early postoperative period, as the stoma may ooze a small amount of blood. However, if the drainage is excessive or persistent, it should be reported.
Choice C reason: A shiny, moist stoma is also a sign of a healthy stoma. The stoma should be moist and have a pink or red color, similar to the inside of the mouth.
Choice D reason: A purplish colored stoma indicates compromised blood flow and is a sign of ischemia. This is a serious complication that requires immediate medical attention to prevent tissue death.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Assessing the cranial nerves is important, but it is not the immediate next step after implementing droplet precautions for suspected bacterial meningitis.
Choice B reason: Decreasing environmental stimuli can help reduce the risk of seizures and is a supportive measure for a patient with suspected bacterial meningitis.
Choice C reason: Closing the room is part of implementing droplet precautions but is not an action that needs to be initiated by the nurse as it should already be in place.
Choice D reason: Administering an antipyretic may be necessary if the patient has a fever, but it is not the immediate next action after droplet precautions.
Correct Answer is C
Explanation
Choice A reason: The blood should not be infusing for 5 hours as transfusions of packed RBCs should be completed within 2 to 4 hours to minimize the risk of bacterial growth and transfusion reactions.
Choice B reason: Medications should not be administered through the same IV line as blood products due to the risk of reactions and interactions.
Choice C reason: The packed RBCs are indeed connected by Tubing to normal saline, which is used to keep the line open and prevent clotting.
Choice D reason: The drip chamber should not be filled completely with blood as it is necessary to monitor the drip rate and to ensure that air does not enter the line.
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