A client with bladder cancer had surgical placement of a ureter ileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?
Mucous strings floating in the drainage.
Red edematous stomal appearance.
Stomal output of 40 mL in the last hour.
Liquid brown drainage from the stoma.
The Correct Answer is D
Choice A reason: Mucous strings in the drainage are normal as mucus is produced by the intestine, which is now part of the urinary diversion.
Choice B reason: A red edematous stomal appearance can be expected postoperatively as part of the normal healing process.
Choice C reason: Stomal output of 40 mL in the last hour is within the normal range for postoperative urinary output.
Choice D reason: Liquid brown drainage from the stoma could indicate a problem such as an infection or bowel content leakage and should be reported immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Teaching for client care after discharge often involves patient education and planning, which are complex tasks typically reserved for registered nurses due to their scope of practice.
Choice B reason: Evaluating and updating plans of care are responsibilities that involve clinical judgment and are usually performed by registered nurses.
Choice C reason: Initial sterile wound care may require assessment and decision-making that are within the registered nurse's scope of practice.
Choice D reason: Validating prescribed intravenous flow rates is a task that can be delegated to a practical nurse, as it involves monitoring and ensuring that the flow rates are set according to the prescribed orders, which is within the practical nurse's scope of practice.
Correct Answer is D
Explanation
Choice A reason: Heat and cold therapy can help manage symptoms but are not directly related to health promotion and teaching.
Choice B reason: Avoiding foods containing purine is more related to conditions like gout, not rheumatoid arthritis.
Choice C reason: Immobilization of affected joints is not a health promotion strategy and can actually worsen rheumatoid arthritis symptoms over time.
Choice D reason: Prevention through nutrition and exercise is a key component of health promotion and teaching for clients with rheumatoid arthritis, as it can help manage symptoms and improve overall health.
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