A nurse in a Post Anesthesia Care Unit (PACU) is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?
Rose budlike stoma orifice
Stoma oozing red drainage
Shiny, moist stoma
Purplish colored stoma
The Correct Answer is D
Choice A reason: A rosebud like stoma orifice is a normal appearance for a new colostomy, indicating that the stoma is healthy and not in distress.
Choice B reason: Red drainage from a stoma can be normal, especially in the early postoperative period, as the stoma may ooze a small amount of blood. However, if the drainage is excessive or persistent, it should be reported.
Choice C reason: A shiny, moist stoma is also a sign of a healthy stoma. The stoma should be moist and have a pink or red color, similar to the inside of the mouth.
Choice D reason: A purplish colored stoma indicates compromised blood flow and is a sign of ischemia. This is a serious complication that requires immediate medical attention to prevent tissue death.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is correct because staying well hydrated can help prevent gout attacks and kidney stones, which can be a side effect of allopurinol.
Choice B reason: This is incorrect. Aspirin can interfere with allopurinol and may increase the risk of gout attacks; therefore, it is not recommended without consulting a healthcare provider.
Choice C reason: This is incorrect. Allopurinol does not need to be taken on an empty stomach; it can be taken with or without food.
Choice D reason: This is correct. Allopurinol should not be crushed or chewed; it should be swallowed whole.
Correct Answer is C
Explanation
Choice A reason: This choice is incorrect. Painless, raised purple nodules on the hard palate are not typically indicative of squamous cell carcinoma.
Choice B reason: This choice is incorrect. A small macule with a yellow-brown scale does not describe squamous cell carcinoma, which often presents as a firm nodule with a scaly crust.
Choice C reason: This is the correct choice. Squamous cell carcinoma can present as a firm nodule with a hard, scaly crust on the skin.
Choice D reason: Yellow white patches of growth on the tongue are more indicative of conditions such as oral leukoplakia, not squamous cell carcinoma.
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