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: Urine specific gravity measures the kidney's ability to concentrate urine. A normal range is typically 1.005–1.030. A value of 1.020 indicates adequate hydration and suggests that the patient is responding well to IV fluid therapy.
Choice B reason: Serum sodium levels reflect electrolyte balance. The normal range is 135–145 mEq/L. A level of 165 mEq/L is significantly elevated, indicating hypernatremia, which could be a sign of inadequate hydration and not a positive response to treatment.
Choice C reason: Hematocrit represents the proportion of blood volume occupied by red blood cells. Normal ranges are 38.3–48.6% for men and 35.5–44.9% for women. A hematocrit of 48% is at the upper limit of normal and does not specifically indicate the effectiveness of dehydration treatment.
Choice D reason: Blood urea nitrogen (BUN) levels can indicate renal function and hydration status. The normal range is 7–20 mg/dL. A BUN of 12 mg/dL is within the normal range and does not specifically reflect the patient's response to IV fluids for dehydration.
Correct Answer is C
Explanation
Choice A reason: Metabolic acidosis is characterized by a low pH and a low HCO3. However, George's HCO3 is within normal range, indicating that metabolic acidosis is not the primary issue.
Choice B reason: Partially compensated metabolic acidosis would present with a low pH and a low HCO3, along with a low PaCO2 as the body attempts to compensate. George's PaCO2 is elevated, which is not consistent with this condition.
Choice C reason: George's high PaCO2 and near normal HCO3 suggest that his primary issue is respiratory acidosis. The body has begun to compensate by retaining HCO3, making it partially compensated.
Choice D reason: Uncompensated respiratory acidosis would present with an elevated PaCO2 and a normal HCO3. Since George's HCO3 is elevated, it indicates partial compensation.
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