Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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?
A. Shiny, moist stoma
A shiny, moist stoma is generally a healthy sign, indicating good blood supply and adequate hydration of the stoma tissue. It is not a cause for concern.
B. Rosebud-like stoma orifice
A rosebud-like stoma orifice is a normal appearance for some types of stomas. It indicates a healthy stoma with good blood supply. This finding is expected and does not warrant concern.
C. Purplish-colored stoma
A purplish-colored stoma may indicate compromised blood supply to the stoma, which is a serious concern and should be reported to the provider promptly. It may suggest inadequate blood flow to the stoma, which could lead to tissue necrosis.
D. Stoma oozing red drainage
Stoma oozing red drainage may be normal immediately postoperatively. It can be due to some oozing from the surgical site, and if it's minimal and stops after a short while, it's generally not a cause for concern.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med Surg Proctored Exam 6. Take the full exam now
Full Explanation
Choice A reason:
A shiny, moist stoma is generally a healthy sign, indicating good blood supply and adequate hydration of the stoma tissue. It is not a cause for concern.
Choice B reason:
A rosebud-like stoma orifice is a normal appearance for some types of stomas. It indicates a healthy stoma with good blood supply. This finding is expected and does not warrant concern.
Choice C reason:
A purplish-colored stoma may indicate compromised blood supply to the stoma, which is a serious concern and should be reported to the provider promptly. It may suggest inadequate blood flow to the stoma, which could lead to tissue necrosis.
Choice D reason:
Stoma oozing red drainage may be normal immediately postoperatively. It can be due to some oozing from the surgical site, and if it's minimal and stops after a short while, it's generally not a cause for concern.
Similar Questions
A patient has been diagnosed with acute pancreatitis. The nurse is addressing the diagnosis of Acute Pain Related to Pancreatitis. What pharmacologic intervention is most likely to be ordered for this patient?
A. IV hydromorphone (Dilaudid)
IV hydromorphone is an opioid analgesic that can provide effective pain relief and can be titrated to the patient's needs. It's commonly used for severe pain associated with conditions like acute pancreatitis.
B. Oral naproxen (Aleve)
Oral naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that may be used for pain relief, but it's not the first-line treatment for acute pancreatitis. NSAIDs can potentially worsen the condition due to their effects on the gastrointestinal tract.
C. IM meperidine (Demerol)
IM meperidine is an opioid analgesic that can be used for pain relief. However, in severe cases of acute pancreatitis, IV opioids are often preferred for more immediate and precise pain control.
D. Oral oxycodone
Oral oxycodone is another opioid analgesic. However, in cases of acute pancreatitis, especially when pain is severe, IV opioids are often the preferred route of administration for more rapid and reliable pain relief.
Full Explanation
Choice A reason:
IV hydromorphone is an opioid analgesic that can provide effective pain relief and can be titrated to the patient's needs. It's commonly used for severe pain associated with conditions like acute pancreatitis.
Choice B reason:
Oral naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that may be used for pain relief, but it's not the first-line treatment for acute pancreatitis. NSAIDs can potentially worsen the condition due to their effects on the gastrointestinal tract.
Choice C reason:
IM meperidine is an opioid analgesic that can be used for pain relief. However, in severe cases of acute pancreatitis, IV opioids are often preferred for more immediate and precise pain control.
Choice D reason:
Oral oxycodone is another opioid analgesic. However, in cases of acute pancreatitis, especially when pain is severe, IV opioids are often the preferred route of administration for more rapid and reliable pain relief.
A patient with a peptic ulcer disease has had metronidazole (Flagyl) added to his current medication regimen. What health education related to this medication should the nurse provide?
A. Take the medication on an empty stomach.
Taking metronidazole with food can help reduce stomach upset. It is not typically recommended to take on an entirely empty stomach.
B. Take at bedtime to mitigate the effects of drowsiness.
Metronidazole can cause drowsiness, but taking it at bedtime specifically for this reason is not a standard recommendation. It's more important to focus on avoiding alcohol.
C. Take up to one extra dose per day if stomach pain persists.
Taking an extra dose without specific medical advice is not recommended. It's important to follow the prescribed dosing regimen.
D. Avoid drinking alcohol while taking the drug.
Avoiding alcohol while taking metronidazole is crucial. The combination of metronidazole and alcohol can cause severe reactions, including nausea, vomiting, abdominal cramps, headache, and flushing. This interaction can occur for several days after discontinuing metronidazole, so it's essential to abstain from alcohol throughout the course of treatment.
Full Explanation
Choice A reason:
Taking metronidazole with food can help reduce stomach upset. It is not typically recommended to take on an entirely empty stomach.
Choice B reason:
Metronidazole can cause drowsiness, but taking it at bedtime specifically for this reason is not a standard recommendation. It's more important to focus on avoiding alcohol.
Choice C reason:
Taking an extra dose without specific medical advice is not recommended. It's important to follow the prescribed dosing regimen.
Choice D reason:
Avoiding alcohol while taking metronidazole is crucial. The combination of metronidazole and alcohol can cause severe reactions, including nausea, vomiting, abdominal cramps, headache, and flushing. This interaction can occur for several days after discontinuing metronidazole, so it's essential to abstain from alcohol throughout the course of treatment.
A patient's new onset of dysphagia has required insertion of an NG tube for feeding; the nurse has modified the patient's care plan accordingly. What intervention should the nurse
include in the patient's plan of care?
A. Keep the patient in a low Fowler's position when at rest.
Keeping the patient in a low Fowler's position may be helpful for some patients with dysphagia, but it is not a specific intervention related to NG tube care.
B. Connect the tube to continuous wall suction when not in use.
Connecting the tube to continuous wall suction when not in use is not a standard practice for NG tube care. Continuous suction can cause mucosal damage and discomfort for the patient.
C. Confirm placement of the tube prior to each medication administration.
Confirming the placement of the NG tube prior to each medication administration is a crucial safety measure. Incorrect placement can lead to serious complications.
D. Have the patient sip cool water to stimulate saliva production.
Sipping cool water to stimulate saliva production may be beneficial for some patients with dysphagia, but it is not a specific intervention related to NG tube care. The focus should be on confirming the placement of the tube.
Full Explanation
Choice A reason:
Keeping the patient in a low Fowler's position may be helpful for some patients with dysphagia, but it is not a specific intervention related to NG tube care.
Choice B reason:
Connecting the tube to continuous wall suction when not in use is not a standard practice for NG tube care. Continuous suction can cause mucosal damage and discomfort for the patient.
Choice C reason:
Confirming the placement of the NG tube prior to each medication administration is a crucial safety measure. Incorrect placement can lead to serious complications.
Choice D reason:
Sipping cool water to stimulate saliva production may be beneficial for some patients with dysphagia, but it is not a specific intervention related to NG tube care. The focus should be on confirming the placement of the tube.