The nurse is caring for a patient 1-day postoperative after a transverse colostomy. When assessing the stoma, which finding requires the nurse's immediate action?
a. A wet, glistening stoma
b. A stoma with scant marginal bleeding
c. An edematous stoma
d. A purplish-red stoma
D
The purple hue in the new stoma is an indication of reduced perfusion to the stoma and should be reported immediately. A new stoma should have a pink or beefy red color, be slightly edematous, and have some small bleeding around the stoma.
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Which of the following trends should the psychiatric nurse consider when engaged in planning for
future managed behavioral health organization services? (More than one answer may be correct.) A. Cost constraints will continue. B. Community-based care will evolve. C. Case management is a necessary skill. D. The prevalence of dementia is falling. E. Cultural diversity in the United States is decreasing.
The nurse is working in the emergency department when a physician asks for help as the client is performing a Romberg test. In which position would the nurse stand to be most helpful?
A) The nurse would stand directly in front of the client. B) The nurse would stand between the client and physician. C) The nurse would stand across the room but in direct alignment from the client. D) The nurse would stand laterally to the client, opposite side to where the physician is standing.
After administration of epidural anesthesia during labor, the patient develops a temperature of 37.8°C (100.1°F). The spouse asks if the patient is "getting sick." How should the nurse respond to the patient and spouse?
A) "We will have to take her temperature every 30 minutes and might start antibiotics." B) "This elevation in temperature is a possible side effect of the anesthesia. We will notify the provider and assess temperature again in an hour." C) "Can you tell me if you have been exposed to any illnesses you might be developing?" D) "Due to the length of your labor, you might be dehydrated and that may cause your temperature to rise, let's get you something to drink."
A client is to take Demerol 35 mg IM. You have Demerol 50 mg per cc. How many cc will you administer?
A) 0.5 cc B) 0.7 cc C) 0.9 cc D) 1.3 cc