A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?

Rosebud-like stoma orifice

Stoma oozing red drainage

Shiny, moist stoma

Purplish-colored stoma

None

Answer and Explanation

The Correct Answer is D

Choice A: Rosebud-like Stoma Orifice

A rosebud-like stoma orifice is typically a normal appearance for a new stoma. The stoma should be moist, pink to red in color, and protrude slightly from the abdomen, resembling a rosebud. This appearance indicates good blood flow and proper healing. Therefore, this finding does not usually require immediate reporting to the provider.

Choice B: Stoma Oozing Red Drainage

While some minor bleeding or oozing can be normal immediately after surgery, persistent or significant red drainage from the stoma could indicate a complication such as infection or trauma to the stoma site. This finding should be monitored closely, but it is not as immediately concerning as a purplish-colored stoma, which indicates a more severe issue.

Choice C: Shiny, Moist Stoma

A shiny, moist stoma is a sign of a healthy stoma. The stoma should always appear moist and slightly shiny due to the mucus produced by the intestinal lining. This finding is normal and does not require reporting to the provider.

Choice D: Purplish-Colored Stoma

A purplish-colored stoma is an immediate concern and should be reported to the provider. This discoloration can indicate compromised blood flow to the stoma, which can lead to tissue necrosis if not addressed promptly. Ensuring adequate blood supply is crucial for the stoma’s viability and the patient’s overall health. Immediate medical intervention is necessary to prevent further complications.

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Correct Answer is ["A"]

Explanation

Choice A Reason:

Suction equipment at the bedside.

Having suction equipment at the bedside is crucial for a client with status epilepticus. During a seizure, there is a risk of aspiration due to excessive salivation or vomiting. Suction equipment allows the nurse to quickly clear the airway, preventing aspiration and ensuring the client can breathe properly. This precaution is essential to maintain the client’s airway and prevent complications such as aspiration pneumonia.

Choice B Reason:

Continuous sedation.

Continuous sedation is not typically a standard precaution for all clients with status epilepticus. While sedation may be necessary in some cases to control seizures, it is not a universal precaution. The primary goal is to stop the seizure activity and stabilize the client. Continuous sedation may be used in specific situations under close medical supervision, but it is not a general precaution that nurses implement for all clients with status epilepticus.

Choice C Reason:

Side rails padded.

Padding the side rails of the bed is an important precaution to prevent injury during a seizure. Clients experiencing seizures may have uncontrolled movements, which can lead to injury if they hit the hard surfaces of the bed. Padded side rails help to cushion these impacts, reducing the risk of bruises, cuts, or fractures. This precaution is essential for ensuring the client’s safety during seizure activity.

Choice D Reason:

Bed in low position.

Keeping the bed in a low position is another important safety measure. If a client with status epilepticus were to fall out of bed during a seizure, the lower height reduces the risk of serious injury. This precaution helps to minimize the impact of any potential falls, ensuring the client’s safety. It is a simple yet effective measure to prevent harm during seizure episodes.

Choice E Reason:

Intravenous (IV) access.

Establishing intravenous (IV) access is critical for a client with status epilepticus. IV access allows for the rapid administration of medications needed to control seizures and manage the client’s condition. In an emergency, quick access to the bloodstream is essential for delivering life-saving treatments. This precaution ensures that the medical team can promptly and effectively intervene to stop the seizure activity.

Correct Answer is ["31"]

Explanation

Let’s calculate the IV infusion rate step by step.

Step 1: Determine the total volume to be infused.

The total volume ordered is 1,000 mL.

Step 2: Determine the total time for the infusion.

The total time is 8 hours.

Step 3: Calculate the infusion rate in mL per hour.

Total volume (1,000 mL) ÷ Total time (8 hours) = 125 mL per hour.

Result: 125

Step 4: Determine the drop factor.

The IV tubing delivers 15 drops per milliliter.

Step 5: Calculate the infusion rate in drops per minute.

Infusion rate (125 mL per hour) × Drop factor (15 drops per mL) = 1,875 drops per hour.

Result: 1,875

Step 6: Convert the infusion rate to drops per minute.

Total drops per hour (1,875 drops) ÷ 60 minutes = 31.25 drops per minute.

Result: 31.25

Step 7: Round the result to the nearest whole number if necessary.

31.25 rounded to the nearest whole number is 31.

The nurse should run the IV infusion at a rate of 31 drops per minute.

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A nurse in a 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

A client has been admitted with new-onset status epilepticus. Which seizure precautions would the nurse implement? (Select all that apply.)

Correct Answer is ["A"]

Explanation

The doctor orders dextrose 5% in water 1,000 mL to be infused over 8 hours. The IV tubing delivers 15 drops per milliliter. The nurse in charge should run the IV infusion at a rate of: NOTE: Enter ONLY THE NUMBER DO NOT enter the unit of measurement

Correct Answer is ["31"]

Explanation

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