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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
IV hydromorphone is an opioid analgesic that can provide effective pain relief and can be titrated to the patient's needs. It's commonly used for severe pain associated with conditions like acute pancreatitis.
Choice B reason:
Oral naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that may be used for pain relief, but it's not the first-line treatment for acute pancreatitis. NSAIDs can potentially worsen the condition due to their effects on the gastrointestinal tract.
Choice C reason:
IM meperidine is an opioid analgesic that can be used for pain relief. However, in severe cases of acute pancreatitis, IV opioids are often preferred for more immediate and precise pain control.
Choice D reason:
Oral oxycodone is another opioid analgesic. However, in cases of acute pancreatitis, especially when pain is severe, IV opioids are often the preferred route of administration for more rapid and reliable pain relief.
Correct Answer is A
Explanation
Choice A reason:
The urea breath test is typically used to diagnose Helicobacter pylori (H. pylori) infection in the stomach. H. pylori can lead to gastritis and ulcers, which can interfere with nutrient absorption and contribute to imbalanced nutrition.
Choice B reason:
Impaired dentition related to gingivitis is not directly related to the need for a urea breath test. This diagnosis pertains to dental health, not gastric health.
Choice C reason:
Diarrhea related to Clostridium difficile infection is not directly related to the need for a urea
breath test. This diagnosis pertains to a bacterial infection in the colon, not H. pylori infection in the stomach.
Choice D reason:
Risk for impaired skin integrity related to peptic ulcers is also not directly related to the need for a urea breath test. This diagnosis pertains to potential skin breakdown due to ulcers, not the
assessment of H. pylori infection.
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