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 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.

A. Dullness B. Tympany C. Resonance D. Flatness

Correct Answer is C

Explanation

Choice A reason: Dullness on percussion typically indicates increased lung density, such as in conditions where lung tissue is consolidated or fluid-filled. This sound is heard in cases of:Pneumonia (due to alveolar consolidation)Pleural effusion (fluid in the pleural space)Lung tumors (solid masses in lung tissue) Since chronic bronchitis is primarily an airway disease characterized by inflammation and mucus production rather than lung consolidation or fluid accumulation, dullness is not an expected finding..

Choice B reason: Tympany is usually heard over air-filled structures and is not a percussion sound typically associated with chronic bronchitis.

Choice C reason:

Resonance is the normal percussion sound heard over healthy lung fields, indicating air-filled alveoli. Since chronic bronchitis does not cause significant air trapping or lung consolidation, percussion remains resonant rather than hyperresonant (as in emphysema) or dull (as in pneumonia). Thus, resonance is the expected finding in chronic bronchitis because the lung parenchyma remains relatively unaffected despite the chronic airway inflammation.

Choice D reason: Flatness is heard over very dense tissue, such as muscle or bone, and is not characteristic of chronic bronchitis.

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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?

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