A nurse in a post-anesthesia care unit (PACU) is assessing a patient who has a newly created colostomy. What findings should the nurse report to the provider?
Purplish-colored stoma.
Rosebud-like stoma orifice.
Stoma oozing red drainage.
Shiny, moist stoma.
The Correct Answer is A
Choice A rationale
A purplish-colored stoma may indicate compromised circulation, which is a serious condition that requires immediate medical attention18.
Choice B rationale
A rosebud-like stoma orifice is a normal finding and does not need to be reported18.
Choice C rationale
A stoma oozing red drainage is a normal finding immediately after surgery and does not need to be reported18.
Choice D rationale
A shiny, moist stoma is a normal finding and does not need to be reported18.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Full thickness skin loss with visible bone is not described in the question. This would be a description of a stage IV pressure ulcer, which involves full thickness tissue loss with exposed bone, tendon, or muscle.
Choice B rationale
Intact skin with localized erythema is not described in the question. This would be a description of a stage I pressure ulcer, which involves intact skin with non-blanchable redness of a localized area usually over a bony prominence.
Choice C rationale
Partial-thickness skin loss with red tissue is not described in the question. This would be a description of a stage II pressure ulcer, which involves partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.
Choice D rationale
Full thickness skin loss with visible adipose tissue is the condition described in the question. This would be a description of a stage III pressure ulcer, which involves full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed.
Correct Answer is ["A","B","D"]
No explanation
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