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 B

Explanation

A. A rapid, irregular heart rate (e.g., atrial fibrillation) is common in mitral valve stenosis due to atrial enlargement but does not necessarily require immediate intervention unless it leads to severe symptoms like syncope or stroke.

B. Blood-tinged sputum could indicate pulmonary edema or pulmonary hypertension, both of which are serious complications of mitral valve stenosis. This finding warrants immediate intervention as it may signify acute heart failure or other critical complications requiring prompt treatment.

D. Swollen feet and ankles are common signs of fluid retention in heart failure, but they do not require immediate intervention compared to the potential complications of atrial fibrillation.

A. Client's healthcare power of attorney. B. Increasing confusion of the client. C. Fall at home as reason for admission. D. Currently prescribed medications.

Correct Answer is B

Explanation

A. Client's healthcare power of attorney: While important, this information may not be
immediately relevant to the client's current condition and the reason for contacting the healthcare provider.
B. Increasing confusion of the client: This information indicates a change in the client's status and is the most pertinent to the client's current condition, warranting immediate attention.
C. Fall at home as reason for admission: While important for background information, the reason for admission is already known, and the focus of the communication should be on the client's current status.
D. Currently prescribed medications: This information is important but may not be the priority when reporting a change in the client's condition.

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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?

Nursing Test Bank

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Explanation

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Explanation

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