The nurse is caring for a client with a heart rate of 143 beats/min with atrial fibrillation. Which assessment data will the nurse anticipate? Select all that apply:

Choice A: He is NPO until the speech-language pathologist performs a swallowing evaluation.

This is the most appropriate response. NPO stands for “nil per os,” which means nothing by mouth. After a stroke, it is crucial to assess the patient’s ability to swallow safely to prevent aspiration, which can lead to pneumonia and other complications. A speech-language pathologist is trained to evaluate swallowing function and determine the safest diet for the patient. Until this evaluation is completed, the patient should not consume any food or liquids.

Choice B: Be sure to sit him up when you are feeding him to make him feel more natural.

While sitting the patient up during feeding is important to reduce the risk of aspiration, it is not sufficient on its own. Without a proper swallowing evaluation, feeding the patient could still pose significant risks. Therefore, this choice is not the most appropriate response.

Choice C: You may give him a full-liquid diet, but please avoid solid foods until he gets stronger.

A full-liquid diet might seem like a safer option, but without a swallowing evaluation, there is still a risk of aspiration. The patient’s ability to handle even liquids needs to be assessed by a professional before any oral intake is allowed.

Choice D: Just be sure to add some thickener in his liquids to prevent choking and aspiration.

Thickening liquids can help manage dysphagia, but this should only be done after a swallowing evaluation has determined the appropriate consistency. Administering thickened liquids without an evaluation could still result in aspiration if the patient has severe swallowing difficulties.

Choice A Reason:

A rosebud-like stoma orifice is a normal finding for a newly created colostomy. This appearance indicates that the stoma is healthy and well-formed. The stoma should protrude slightly from the abdomen and have a pink or red color, similar to the inside of the mouth. This indicates good blood flow and proper healing. Therefore, a rosebud-like stoma orifice does not need to be reported to the provider.

Choice B Reason:

A stoma oozing red drainage can be concerning, but it is not uncommon for a new stoma to have some minor bleeding or oozing, especially in the immediate postoperative period. This can occur due to the delicate nature of the tissue and the recent surgical intervention. However, if the drainage is excessive or persistent, it should be monitored closely and reported if it does not improve. Minor oozing is generally expected and does not necessarily indicate a serious problem.

Choice C Reason:

A shiny, moist stoma is a normal finding and indicates that the stoma is healthy. The stoma should be moist and have a shiny appearance, similar to the inside of the mouth. This moisture is necessary for the proper function and health of the stoma. Therefore, a shiny, moist stoma does not need to be reported to the provider.

Choice D Reason:

A purplish-colored stoma is an abnormal finding and should be reported to the provider immediately. This discoloration can indicate compromised blood flow to the stoma, which can lead to tissue necrosis if not addressed promptly. A healthy stoma should be pink or red, indicating good blood circulation. Any deviation from this color, especially a purplish or dark color, is a sign of potential ischemia or other serious complications that require immediate medical attention.