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 C
Explanation
Choice A reason: Cooling the bottle is not necessary and shaking it is only required if the instructions specify to do so to mix the medication.
Choice B reason: Inserting the tip of the dropper into the ear canal is not recommended as it can introduce bacteria and cause injury.
Choice C reason: Pulling the pinna up and back in adults helps to straighten the ear canal, allowing for proper delivery of the medication.
Choice D reason: Administering the drops with the head held upright is not the correct method; the head should be tilted to allow the drops to flow down into the ear canal.
Correct Answer is ["B","C"]
Explanation
Choice A reason: Telling the parents that the procedure is 100% effective and safe is misleading and unethical. No medical procedure can be guaranteed to be completely effective and without risk.
Choice B reason: Providing the parents with ideas about how to make their child feel better after the procedure can be comforting and can help them feel more involved and prepared for post-procedure care.
Choice C reason: Finding a comfortable area for the parents to wait that is close to the procedure area can help reduce their anxiety by keeping them informed and involved in the process.
Choice D reason: Limiting visitation can increase anxiety as it separates the parents from their child, which can be distressing for both the child and the parents.
Choice E reason: Not providing any specifics on the amount of time the procedure will take can increase anxiety due to uncertainty. It is better to give a realistic time frame when possible.
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