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

Answer and Explanation

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.

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Correct Answer is ["D","E"]

Explanation

Choice A reason: Bradycardia, or a slower than normal heart rate, is not typically an indication of infection. It can be related to other health issues or medication effects.

Choice B reason: An increase in platelets, or thrombocytosis, can occur in response to various conditions, but it is not a specific indicator of infection in diabetic foot pain.

Choice C reason: An increase in RBCs, or erythrocytosis, is generally not associated with infection. It could indicate other conditions such as polycythemia vera.

Choice D reason: Localized edema, or swelling, can be a sign of infection, especially if accompanied by other symptoms such as redness, warmth, and pain.

Choice E reason: An increase in neutrophils, a type of white blood cell, often indicates the body's response to an infection. Neutrophils are part of the immune system's first line of defense against pathogens.

A. Serum creatinine 1.8 mg/dL B. Magnesium 2.0 mEq/L C. Blood urea nitrogen (BUN) 20 mg/dL D. Serum osmolality 290 mOsm/kg H2O

Correct Answer is A

Explanation

Choice A reason: Serum creatinine is a waste product from the normal breakdown of muscle tissue. A level of 1.8 mg/dL is higher than the normal range (0.61.2 mg/dL for females), indicating impaired kidney function and an increased risk of AKI.

Choice B reason: A magnesium level of 2.0 mEq/L is within the normal range (1.72.2 mEq/L) and does not typically indicate an increased risk of AKI.

Choice C reason: A BUN level of 20 mg/dL is within the normal range (720 mg/dL) and does not suggest an increased risk of AKI by itself.

Choice D reason: A serum osmolality of 290 mOsm/kg H2O is within the normal range (275295 mOsm/kg H2O) and does not indicate an increased risk of AKI.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the client for which of the following alterations as indications that the client has an infection? (Select all that apply.)

Correct Answer is ["D","E"]

Explanation

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Correct Answer is A

Explanation

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