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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale

Constipation is not typically resolved by diluting enteral feeding formula.

Choice B rationale

Diarrhea can be a common side effect of enteral feeding, and diluting the formula can help manage this.

Choice C rationale

While electrolyte imbalance can occur with enteral feeding, diluting the formula is not typically done to resolve this issue.

Choice D rationale

Delayed gastric emptying is not typically resolved by diluting enteral feeding formula.

A. Full-thickness skin loss with visible bone. B. Full-thickness skin loss with visible adipose tissue. C. Skin remains intact with localized erythema. D. Partial-thickness skin loss with red tissue in the wound bed.

Correct Answer is C

Explanation

Choice A rationale

Full-thickness skin loss with visible bone is characteristic of a stage 4 pressure injury, not a stage 1 pressure injury.

Choice B rationale

Full-thickness skin loss with visible adipose tissue is characteristic of a stage 3 pressure injury, not a stage 1 pressure injury.

Choice C rationale

In a stage 1 pressure injury, the skin remains intact with localized erythema. The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue.

Choice D rationale

Partial-thickness skin loss with red tissue in the wound bed is characteristic of a stage 2 pressure injury, not a stage 1 pressure injury.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who is receiving enteral tube feeding and has a new prescription to dilute the formula. The nurse recognizes this is being done to resolve which of the following conditions?

Correct Answer is B

Explanation

A nurse is evaluating a patient who has a stage 1 pressure injury. What findings should the nurse anticipate?

Correct Answer is C

Explanation

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