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 C
Explanation
Choice A reason: Weighing the client daily is important for monitoring fluid balance but is not the most immediate action to prevent an Addisonian crisis.
Choice B reason: Restricting fluid intake is not appropriate for a client at risk for Addisonian crisis, as they may require increased fluids to prevent dehydration.
Choice C reason: This is the correct action. Clients with Addison's disease require corticosteroids to replace the hormones that their adrenal glands are not producing.
Choice D reason: Providing a low carbohydrate diet is not relevant to the prevention of an Addisonian crisis.
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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