A nurse in a post-anesthesia care unit (PACU) is assessing a patient who has a newly created colostomy. What findings should the nurse report to the provider?

Purplish-colored stoma.

Rosebud-like stoma orifice.

Stoma oozing red drainage.

Shiny, moist stoma.

Answer and Explanation

The Correct Answer is A

Choice A rationale

A purplish-colored stoma may indicate compromised circulation, which is a serious condition that requires immediate medical attention18.

Choice B rationale

A rosebud-like stoma orifice is a normal finding and does not need to be reported18.

Choice C rationale

A stoma oozing red drainage is a normal finding immediately after surgery and does not need to be reported18.

Choice D rationale

A shiny, moist stoma is a normal finding and does not need to be reported18.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

The client is at greatest risk for developing a Pressure ulcer due to Limited mobility.

The client’s limited mobility and the need for assistance to turn and transfer out of bed increases the risk of pressure ulcers. Pressure ulcers, also known as bedsores, are injuries to the skin and underlying tissue resulting from prolonged pressure on the skin. They most often develop on skin that covers bony areas of the body, such as the heels, ankles, hips, and tailbone. People most at risk of pressure ulcers are those with a medical condition that limits their ability to change positions or those who spend most of their time in a bed or chair.

A. Mix the three medications together prior to administering. B. Maintain the head of the bed in a flat position for 30 min following medication administration. C. Flush the NG feeding tube with 30 mL of water immediately following medication administration. D. Dilute each medication with 10 mL of tap water.

Correct Answer is C

Explanation

Rationale:

When administering multiple liquid medications through an NG tube, it’s important to administer each medication separately to prevent drug interactions. After each medication, the NG tube should be flushed with 30 mL of water to ensure that the medication has been fully administered and to prevent the tube from becoming clogged.

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A nurse in a post-anesthesia care unit (PACU) is assessing a patient who has a newly created colostomy. What findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

A nurse is preparing to administer three liquid medications to a client who has an NG feeding tube with continuous enteral feedings. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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