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 A

Explanation

Choice A reason: play a crucial role in transplant rejection. They can recognize and attack foreign tissues, including transplanted organs, leading to rejection. This immune response is a significant concern in transplant medicine, and managing T cell activity is essential for the success of organ transplants.

Choice B reason: While anaphylaxis is an acute allergic reaction, it is more commonly associated with the release of histamines and other mediators from mast cells and basophils. can contribute to the severity of the reaction, but they are not the primary cells involved in anaphylaxis.

Choice C reason: Bacterial phagocytosis is primarily the function of phagocytes like neutrophils and macrophages. do not directly engage in phagocytosis but can activate other immune cells that do.

Choice D reason: Hay fever, or allergic rhinitis, involves an immune response to airborne allergens, with contributing to the development of symptoms by helping to produce IgE antibodies. However, the immediate symptoms of hay fever are more directly related to mast cell activation rather than activity.

A. Diabetes mellitus B. Hyperlipidemia C. Gallstones D. Criminal record

Correct Answer is C

Explanation

Choice A reason: Diabetes mellitus is not directly associated with acute pancreatitis. However, longstanding diabetes can lead to chronic pancreatitis due to the damage it causes to the pancreas over time.

Choice B reason: Hyperlipidemia, specifically high levels of triglycerides in the blood, can be a risk factor for acute pancreatitis. Elevated triglyceride levels above 1000 mg/dL can precipitate an episode of acute pancreatitis.

Choice C reason: Gallstones are a common cause of acute pancreatitis. They can block the bile duct, leading to pancreatitis. It's estimated that gallstone disease is responsible for 3040% of acute pancreatitis cases.

Choice D reason: A criminal record is not a medical condition and has no relevance to the development of acute pancreatitis.

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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

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