A client with bladder cancer had surgical placement of a ureteroileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?

Liquid brown drainage from stoma.

Stomal output of 40 mL in the last hour.

Red edematous stomal appearance.

Mucous strings floating in the drainage.

Answer and Explanation

The Correct Answer is A

A. Liquid brown drainage from the stoma is abnormal and could indicate bowel content leakage, suggesting a potential connection between the bowel and the conduit or possible infection. This is a critical finding and should be reported immediately.

- B: A stomal output of 40 mL in the last hour is within normal limits postoperatively, as urine production can vary and this amount does not suggest acute complications.

C. A red and edematous stomal appearance is normal in the immediate postoperative period and indicates adequate blood supply to the stoma.

- D: Mucous strings in the drainage are normal because mucus is produced by the intestinal lining, which is now part of the urinary diversion. This is an expected finding and not a cause for immediate concern.

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Correct Answer is C

Explanation

A. Monitor and document strict intake and output: While monitoring intake and output is
important in managing fluid balance, it may not directly address the potential complications associated with hyperkalemia and hyperglycemia.
B. Assess the serum potassium level every 4 hours: While monitoring potassium levels is important, obtaining a 12-lead electrocardiogram provides immediate information about the cardiac effects of hyperkalemia, which can be life-threatening.
C. Obtain a 12-lead electrocardiogram daily: Hyperkalemia can lead to serious cardiac arrhythmias, including bradycardia, heart block, and ventricular fibrillation. Daily
electrocardiograms can help detect these changes early.
D. Evaluate glucose levels before and after meals: While monitoring glucose levels is important, the immediate concern in this scenario is the potential cardiac effects of hyperkalemia.

A. Encourage the use of ice on the areola. B. Recommend using a breast shield. C. Teach about the use of a breast pump. D. Offer supplemental formula feedings.

Correct Answer is B

Explanation

A. Encouraging the use of ice on the areola is not appropriate for addressing inverted nipples. Ice may cause discomfort and vasoconstriction, making latching more difficult.
B. Recommending the use of a breast shield can help draw out inverted nipples, making it easier for the baby to latch onto the breast. Breast shields can be used temporarily until the nipples
become more erect or until breastfeeding techniques are established.
C. Teaching about the use of a breast pump may be appropriate for establishing milk supply or relieving engorgement, but it does not directly address the issue of inverted nipples or difficulty with latching.
D. Offering supplemental formula feedings should be a last resort and should only be considered if other methods of addressing latch difficulties, such as using a breast shield or seeking
assistance from a lactation consultant, have been unsuccessful.

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A client with bladder cancer had surgical placement of a ureteroileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client who is one day postpartum tells the nurse that her baby cannot latch onto the breast. The nurse determines that the client's nipples are inverted. Which action should the nurse implement?

Correct Answer is B

Explanation

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A client with bladder cancer had surgical placement of a ureteroileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?

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