A nurse in a PACU is assessing a client who has a newly created colostomy. Which of the following findings should the nurse report to the provider?
Rosebud-like stoma orifice
Stoma oozing red drainage
Shiny, moist stoma
Purplish-colored stoma
None
None
The Correct Answer is D
Choice A: Rosebud-like Stoma Orifice
A rosebud-like stoma orifice is typically a normal appearance for a new stoma. The stoma should be moist, pink to red in color, and protrude slightly from the abdomen, resembling a rosebud. This appearance indicates good blood flow and proper healing. Therefore, this finding does not usually require immediate reporting to the provider.
Choice B: Stoma Oozing Red Drainage
While some minor bleeding or oozing can be normal immediately after surgery, persistent or significant red drainage from the stoma could indicate a complication such as infection or trauma to the stoma site. This finding should be monitored closely, but it is not as immediately concerning as a purplish-colored stoma, which indicates a more severe issue.
Choice C: Shiny, Moist Stoma
A shiny, moist stoma is a sign of a healthy stoma. The stoma should always appear moist and slightly shiny due to the mucus produced by the intestinal lining. This finding is normal and does not require reporting to the provider.
Choice D: Purplish-Colored Stoma
A purplish-colored stoma is an immediate concern and should be reported to the provider. This discoloration can indicate compromised blood flow to the stoma, which can lead to tissue necrosis if not addressed promptly. Ensuring adequate blood supply is crucial for the stoma’s viability and the patient’s overall health. Immediate medical intervention is necessary to prevent further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Choice A Reason: High-flow nasal cannula
The high-flow nasal cannula (HFNC) is designed to deliver oxygen at flow rates much higher than 5 liters per minute, typically ranging from 20 to 60 liters per minute. It is used for patients requiring high levels of oxygen and positive airway pressure. Therefore, it is not appropriate for a flow rate of 5 liters per minute.
Choice B Reason: Simple face mask
The simple face mask is suitable for delivering oxygen at flow rates between 6 to 10 liters per minute. However, it can also be used at a flow rate of 5 liters per minute, providing an FiO2 (fraction of inspired oxygen) of approximately 40-60%. This makes it an appropriate choice for the given requirement.
Choice C Reason: Nasal cannula
The nasal cannula is a low-flow oxygen delivery device that can deliver oxygen at flow rates from 1 to 6 liters per minute. At 5 liters per minute, it provides an FiO2 of approximately 40%. It is comfortable for patients and is commonly used for those who need a moderate amount of supplemental oxygen.
Choice D Reason: Non-rebreather mask
The non-rebreather mask is designed to deliver high concentrations of oxygen, typically at flow rates of 10 to 15 liters per minute. It is used in situations where patients need a high FiO2, close to 100%. Therefore, it is not suitable for a flow rate of 5 liters per minute.
Choice E Reason: Venturi mask
The Venturi mask is used to deliver precise oxygen concentrations, typically ranging from 24% to 60% FiO2. It is suitable for patients who require controlled oxygen therapy. While it can be adjusted to deliver oxygen at a flow rate of 5 liters per minute, it is generally used for more specific FiO2 requirements.
Correct Answer is ["C","D","E"]
Explanation
Choice A reason: Stretch marks, also known as striae, are not specific to ascites. They can occur due to rapid weight gain or loss, pregnancy, or other conditions that cause the skin to stretch. While they may be present in individuals with ascites due to rapid abdominal expansion, they are not a primary clinical manifestation of ascites.
Choice B reason: Foul-smelling breath, or halitosis, is not a typical symptom of ascites. It can be associated with various conditions, including poor oral hygiene, gastrointestinal disorders, or liver disease, but it is not a direct indicator of ascites.
Choice C reason: Increased abdominal girth is a primary clinical manifestation of ascites. Ascites is characterized by the accumulation of fluid in the peritoneal cavity, leading to noticeable abdominal distension. This symptom is often accompanied by a feeling of fullness or bloating.
Choice D reason: Visible distended veins, particularly around the abdomen, can be a sign of ascites. This occurs due to increased pressure in the abdominal veins as a result of fluid accumulation. The veins become more prominent and visible under the skin.
Choice E reason: Rapid weight gain is another key indicator of ascites. The accumulation of fluid in the abdomen leads to a significant increase in body weight over a short period. This rapid weight gain is often one of the first signs that prompts further investigation for ascites.
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