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 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.

Correct Answer is ["125"]

Explanation

Step 1 is to understand the question. The patient has been prescribed vancomycin 1 g in 250 mL dextrose 5% (D5W) to be administered over 2 hours via IV intermittent bolus. We need to calculate how many mL/hr the nurse should set the IV pump to deliver.

Step 2 is to calculate the rate. The total volume to be administered is 250 mL and the time for administration is 2 hours. So, the rate is 250 mL ÷ 2 hours = 125 mL/hr.

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

Correct Answer is C

Explanation

A nurse is caring for a patient who has sepsis. The patient has been prescribed vancomycin 1 g in 250 mL dextrose 5% (D5W) to be administered over 2 hours via IV intermittent bolus. How many mL/hr should the nurse set the IV pump to deliver?

Correct Answer is ["125"]

Explanation

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