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. Physical therapy B. Serum cardiac enzyme levels C. MRI of the chest D. Low sodium diet

Correct Answer is C

Explanation

Choice A reason: Physical therapy may be prescribed postoperatively to aid in recovery, but it does not directly interfere with the function of a pacemaker.

Choice B reason: Checking serum cardiac enzyme levels is a common practice after heart surgery to assess for any damage to the heart muscle, which would not typically require clarification in the context of pacemaker insertion.

Choice C reason: An MRI of the chest should be clarified with the healthcare provider because MRI can interfere with pacemaker function. Patients with pacemakers are generally advised to avoid MRI unless the pacemaker is Incompatible, due to the risk of the magnetic field affecting the device's operation.

Choice D reason: A low sodium diet may be recommended for patients with heart conditions to manage blood pressure and fluid retention, but it is not directly related to the care of a pacemaker.

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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

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

Explanation

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