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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Ménière's disease typically presents with vertigo, tinnitus, and hearing loss, not sudden resolution of ear pain with otorrhea.

Choice B reason: Mastoiditis may cause ear pain and drainage, but it is usually accompanied by fever and tenderness over the mastoid bone, not sudden pain resolution.

Choice C reason: A perforated tympanic membrane can lead to the sudden resolution of ear pain followed by drainage, as the pressure causing the pain is relieved when the eardrum ruptures.

Choice D reason: Acoustic neuroma typically presents with progressive hearing loss and tinnitus, not ear pain or otorrhea.

A. Dehydration B. Burns C. Shivering D. Seizures

Correct Answer is C

Explanation

Choice A reason: Dehydration is a concern with fever, but it is not a direct complication of hypothermia blanket therapy. It is important to ensure adequate hydration, but the primary concern with hypothermia therapy is not dehydration.

Choice B reason: Burns could occur if the hypothermia blanket malfunctions or is used improperly. However, modern devices have safety features to prevent burns, making this a less likely complication.

Choice C reason: Shivering is a natural response to cooling and can occur as the body attempts to generate heat in response to the lowered temperature from the hypothermia blanket. It can be counterproductive to the therapy and may need to be controlled with medications.

Choice D reason: Seizures are not a typical complication of hypothermia blanket therapy. While meningitis can cause seizures due to inflammation of the brain, the hypothermia blanket itself does not induce seizures.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who reports ear pain for the past three days that has suddenly resolved. The client has a new onset of otorrhea (drainage from the ear). The nurse should recognize the client has manifestations of which of the following conditions?

Correct Answer is C

Explanation

A nurse is caring for a client who has meningitis and a temperature of 39.7°C (103.5°F). The client is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must be carefully observed for which of the following complications?

Correct Answer is C

Explanation

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