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 A

Explanation

Choice A reason: Weight bearing exercises, such as walking, jogging, and dancing, are beneficial for building and maintaining bone density. These activities force the body to work against gravity, stimulating bone formation and slowing bone loss.

Choice B reason: While bone density scans are useful for diagnosing osteoporosis, they are not typically used as a preventive measure but rather as a diagnostic tool to assess bone health.

Choice C reason: Drinking coffee in moderation is not directly related to preventing osteoporosis. Excessive caffeine intake can interfere with calcium absorption, but a single cup is unlikely to have a significant impact.

Choice D reason: Increasing sodium intake is not recommended as it can lead to calcium loss through urine, which is counterproductive for bone health.

A. Perform neurological checks every 2 hours. B. Position the patient in a chair every 2 hours. C. Inspect clear drainage on the spinal dressing. D. Continue criminal checks.

Correct Answer is A

Explanation

Choice A reason: Neurological checks are essential after spinal surgery to monitor for any changes or deterioration in the patient's neurological status. The frequency of these checks can vary based on the patient's condition, but a common standard is to perform them every 4 hours or sooner. However, in some cases, especially immediately post operation, checks may be required more frequently, such as every 2 hours, to ensure any complications are identified and managed promptly.

Choice B reason: While mobilization is an important aspect of postsurgical care to prevent complications such as deep vein thrombosis, positioning a patient in a chair every 2 hours may not be appropriate immediately following spinal surgery. The patient's mobility and pain level must be assessed, and activities should be gradually increased as tolerated.

Choice C reason: Inspecting the spinal dressing is important to identify signs of infection or complications. However, clear drainage is not typically expected and could indicate cerebrospinal fluid leakage, which requires immediate medical attention.

Choice D reason: The term "criminal checks" is not relevant to nursing care and seems to be a typographical error. The nurse's focus should be on clinical assessments and interventions related to the patient's health status.

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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

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