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 B

Explanation

Choice A reason: The medication administration record is an important document, but it is not the primary source for verification before administering blood products. It is used to record the administration after the fact.

Choice B reason: The identification wristband is the priority source for verification. It contains the client's essential information, such as name and hospital ID, which must match the blood product label to ensure patient safety⁸.

Choice C reason: The order sheet contains the physician's orders, which is crucial for verifying what has been prescribed but is secondary to the identification wristband for the actual administration process.

Choice D reason: The chart contains a comprehensive record of the client's medical history and care but is not the primary source for verification when administering blood products.

A. Decreased neutrophil count B. Elevated eosinophil count C. Increased hemoglobin level D. Elevated platelet count

Correct Answer is B

Explanation

Choice A reason: A decreased neutrophil count is not typically associated with parasitic infections. Neutrophils are a type of white blood cell that responds to bacterial infections, so a decrease might be seen in viral infections or certain inflammatory conditions, but not specifically indicative of a parasitic infection.

Choice B reason: An elevated eosinophil count is often associated with parasitic infections, especially those involving tissue invasion. Eosinophils are white blood cells that play a crucial role in the immune response against parasitic infections. Normal eosinophil counts range from 0 to 500 cells per microliter of blood.

Choice C reason: An increased hemoglobin level is generally not related to the presence of a parasitic infection. Hemoglobin levels can be affected by various conditions, but they do not serve as a specific indicator for parasitic infections.

Choice D reason: An elevated platelet count can occur in various conditions, including inflammatory states and infections, but it is not a specific marker for parasitic infections. Platelets are components of blood that help with clotting and would not be used to differentiate between bacterial and parasitic infections.

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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

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Explanation

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