Certified Medical-Surgical Registered Nurse Practice Exam

What finding should prompt a nurse to urgently contact the physician regarding Mrs. Warren's stoma?

1. The stoma appears pale and dry.

2. The stoma appears red and shiny.

3. There is 200 mL of dark green output from the stoma.

4. There is 50 mL of serosanguinous drainage from the stoma.

The correct answer is: The stoma appears pale and dry.

The finding that should prompt a nurse to urgently contact the physician regarding Mrs. Warren's stoma is when the stoma appears pale and dry. A stoma that is pale and dry may indicate compromised blood flow, which could lead to ischemia and tissue necrosis. It is important for a stoma to maintain a healthy, vascular appearance, typically characterized by a red and shiny appearance, which indicates that it is receiving adequate blood supply and is functioning properly. The other findings, while they may require monitoring, do not indicate the same level of urgency. A stoma that is red and shiny is a normal and healthy appearance, suggesting good blood flow and tissue health. Dark green output from the stoma could be expected depending on the individual's diet and the location of the stoma, and serosanguinous drainage can be common postoperatively, as it may represent normal healing, unless excessive or accompanied by other concerning symptoms.