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?

Shiny, moist stoma

Rosebud-like stoma orifice

Purplish-colored stoma

Stoma oozing red drainage

Answer and Explanation

The Correct Answer is C

Choice A reason:

A shiny, moist stoma is generally a healthy sign, indicating good blood supply and adequate hydration of the stoma tissue. It is not a cause for concern.

Choice B reason:

A rosebud-like stoma orifice is a normal appearance for some types of stomas. It indicates a healthy stoma with good blood supply. This finding is expected and does not warrant concern.

Choice C reason:

A purplish-colored stoma may indicate compromised blood supply to the stoma, which is a serious concern and should be reported to the provider promptly. It may suggest inadequate blood flow to the stoma, which could lead to tissue necrosis.

Choice D reason:

Stoma oozing red drainage may be normal immediately postoperatively. It can be due to some oozing from the surgical site, and if it's minimal and stops after a short while, it's generally not a cause for concern.

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Correct Answer is B

Explanation

Choice A reason:

Monitoring creatinine levels is important, but it may not be the top priority in this situation.

Choice B reason:

This statement is correct. Given the severe diarrhea associated with Clostridium difficile infection, monitoring potassium levels is crucial to identify and address potential electrolyte imbalances, which can lead to serious complications.

Choice C reason:

Monitoring white blood cell levels is important in the context of infection, but potassium levels are more directly relevant to managing severe diarrhea associated with Clostridium difficile.

Choice D reason:

Hemoglobin levels are important for assessing anemia, but in this context, monitoring potassium levels takes precedence due to the potential for electrolyte imbalances from severe diarrhea.

A. Assess for signs of infection. B. Assess for a patent airway. C. Assess ability to clear oral secretions. D. Assess for ability to communicate.

Correct Answer is B

Explanation

Choice A reason:

While assessing for signs of infection is important, ensuring a patent airway takes precedence immediately following surgery.

Choice B reason:

This statement is correct. Assessing for a patent airway is the top priority in postoperative care to ensure the patient can breathe effectively.

Choice C reason:

Assessing the ability to clear oral secretions is important, but it is secondary to ensuring a patent airway.

Choice D reason:

Assessing the ability to communicate is important, but it is not the immediate priority after surgical resection for oropharyngeal cancer.

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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 nurse is caring for an older adult who has been experiencing severe Clostridium difficile- related diarrhea. When reviewing the patient's most recent laboratory tests, the nurse should prioritize which of the following?

Correct Answer is B

Explanation

A nurse is assessing a patient who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize?

Correct Answer is B

Explanation

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