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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Free Nursing Study Resources

Correct Answer is ["A","B","D"]

Explanation

Choice A reason: Blowing the nose gently is advised to prevent nosebleeds, which can be a risk due to thrombocytopenia.

Choice B reason: Lubricating lips with water-soluble ointment can prevent cracking and bleeding, which is important for a patient with thrombocytopenia.

Choice C reason: Using a straightedge razor is not recommended because it can increase the risk of cuts and bleeding. An electric razor would be safer.

Choice D reason: Brushing teeth with a soft toothbrush is recommended to prevent gum bleeding due to the low platelet count associated with thrombocytopenia.

Choice E reason: Limiting fruit consumption is not necessary for thrombocytopenia unless the patient has a specific condition that requires dietary restrictions.

A. Pain B. Hemorrhage C. Infection D. Urinary retention

Correct Answer is B

Explanation

Choice A reason: Pain is a common postoperative symptom and should be managed appropriately. However, it is not typically considered a priority over other complications that can have more immediate and severe consequences.

Choice B reason: Hemorrhage is a significant risk after TURP and can be life-threatening. It is considered a priority because active bleeding can lead to shock and requires immediate intervention.

Choice C reason: Infection is a potential complication after any surgery, including TURP. While important to monitor for, it is generally not as immediately life-threatening as hemorrhage.

Choice D reason: Urinary retention can occur after TURP, but it is often anticipated and managed with the placement of a urinary catheter. It is a concern but not the highest priority immediately following surgery.

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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 creating a teaching plan for a client who has thrombocytopenia. Which of the following instructions should the nurse include? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

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Correct Answer is B

Explanation

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