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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Asking if there is a particular reason why the parent thinks it's their fault may inadvertently validate feelings of self-blame, which is not helpful in this sensitive situation.
Choice B reason: While reassuring the parent they did nothing wrong is true, it may not address the emotional support the parent needs at this moment.
Choice C reason: Promising a full recovery with surgery may be misleading and give false hope, as outcomes can vary and myelomeningocele often results in some degree of impairment.
Choice D reason: Acknowledging the parent's feelings and the difficulty of the situation provides emotional support and validation without assigning blame or making promises about the outcome.
Correct Answer is D
Explanation
Choice A reason: Children's aspirin is not recommended due to the risk of Reye's syndrome and is not typically used for post-vaccination care.
Choice B reason: While fever can occur after vaccination, not all fevers are serious and can often be managed at home unless they are high or persistent.
Choice C reason: Keeping the child home from daycare is not necessary unless the child is feeling unwell or has a fever.
Choice D reason: Applying a cool pack to the injection site is a common recommendation to reduce discomfort and swelling after vaccinations.
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