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?

Choice A rationale

Emptying the drainage bag when half full is a correct action by the AP4. It is important to empty the drainage bag regularly to prevent infection and maintain accurate intake and output records.

Choice B rationale

Placing the drainage bag on the side rail of the patient’s bed is an incorrect action by the AP4. The drainage bag should be placed below the level of the bladder to prevent backflow of urine, which can lead to infection.

Choice C rationale

Kinking the catheter tubing to obtain a urine specimen is an incorrect action by the AP4. This can cause discomfort to the patient and potentially damage the catheter.

Choice D rationale

Securing the catheter tubing to the patient’s thigh is a correct action by the AP4. This helps to prevent pulling on the catheter, which can cause discomfort and potential damage to the urethra.

Choice A rationale

While observing the patient’s respiratory status is important in all patient care, it is not the priority action in this case. The patient’s decreased level of consciousness and inability to swallow increase the risk of aspiration, which can lead to respiratory complications.

Choice B rationale

Elevating the head of the patient’s bed 30° to 45° is the priority action. A patient who has a decreased level of consciousness and an inability to swallow is at risk for aspiration. Lying down also increases this risk. The priority action by the nurse is to keep the head of the bed elevated to promote gastric emptying and reduce the risk of aspiration.

Choice C rationale

Monitoring intake and output every 8 hours is important for assessing the patient’s hydration status and nutritional needs. However, it is not the priority action in this case. The risk of aspiration due to the patient’s decreased level of consciousness and inability to swallow takes precedence.

Choice D rationale

Checking residual volume every 4 to 6 hours is a standard practice when administering continuous enteral feedings through a gastrostomy tube. It helps to ensure that the patient is tolerating the feedings and not at risk for aspiration due to high gastric residuals. However, in this case, the priority is to prevent aspiration by elevating the head of the bed.