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 A
Explanation
Choice A reason: Defibrillation is used in the case of life-threatening cardiac rhythms, such as ventricular fibrillation or pulseless ventricular tachycardia. It is not the first line of treatment for a stable patient with VT.
Choice B reason: CPR is initiated when a patient is unresponsive and not breathing or not breathing normally, indicating cardiac arrest. It is not indicated for a patient who is stable and experiencing VT.
Choice C reason: Elective cardioversion is a procedure where an electrical shock is delivered to the heart to convert an abnormal rhythm back to a normal sinus rhythm. It is typically used for rhythms such as atrial fibrillation or atrial flutter, not first line for VT.
Choice D reason: Radiofrequency catheter ablation is a procedure that uses radiofrequency energy to destroy a small area of heart tissue that is causing rapid and irregular heartbeats. In the case of VT, this procedure is used to target the area causing the abnormal rhythm and is a common treatment for recurrent VT.
Correct Answer is B
Explanation
Choice A reason: Applying a tourniquet just below the elbow is not recommended as the first line of action for a deep laceration unless there is life-threatening hemorrhaging that cannot be controlled by direct pressure. Tourniquets are used as a last resort because they can cause tissue damage.
Choice B reason: Elevating the limb and applying ice can help reduce bleeding and swelling. Elevation uses gravity to help reduce blood flow to the injury, and the cold from the ice constricts blood vessels, further helping to control bleeding and reduce swelling.
Choice C reason: Cleaning the wound is important, but it should not be the first action taken. The initial focus should be on stopping the bleeding. Once bleeding is controlled, the wound can be cleaned to prevent infection.
Choice D reason: Applying pressure directly to the wound with a clean cloth or bandage is the first step in controlling bleeding. However, the question specifies applying pressure above the wound, which would not be effective in controlling bleeding from the wound itself.
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