A nurse is collecting data on a client who is two days postoperative following creation of an ileal conduit. The nurse should report which of the following findings?

Urine in the drainage appliance

Feces in the drainage appliance

Mild edema of the stoma

Redness of the stoma

Answer and Explanation

The Correct Answer is B

a. Urine in the drainage appliance: The presence of urine in the drainage appliance is expected in a client with an ileal conduit, as this is the route for urine to exit the body.

b. Feces in the drainage appliance: An ileal conduit is created for urinary diversion, and feces

should not be present in the drainage appliance. This finding could indicate a complication and should be reported.

c. Mild edema of the stoma: Mild edema of the stoma may be expected in the early postoperative period and may not require immediate reporting unless it worsens.

d. Redness of the stoma: Some redness is normal around a stoma, and it may not require immediate reporting unless there are signs of infection or worsening inflammation.

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Correct Answer is A

Explanation

a. Tetany: A calcium level of 8 mg/dl is low and can be associated with tetany.

b. Constipation:This is associated with hypercalcemia as opposed to hypocalcemia

c. Negative Chvostek sign: A positive Chvostek sign is associated with hypocalcemia, not hypercalcemia.

d. Elevated blood pressure: Elevated calcium levels are not typically associated with elevated blood pressure. Hypertension is not a common manifestation of hypercalcemia.

A. Allow the client to take her morning vitamins. B. Allow the client to keep her tongue stud in. C. Allow the client to keep her hearing aids in. D. Allow the client to consume clear liquids up to the time of surgery.

Correct Answer is C

Explanation

a. Allow the client to take her morning vitamins: This is generally acceptable unless there are specific preoperative instructions regarding medication.

b. Allow the client to keep her tongue stud in: Metallic objects, including tongue studs, are

usually removed before surgery to prevent interference with equipment and to ensure patient safety.

c. Allow the client to keep her hearing aids in: It is important for the client with a hearing

impairment to keep hearing aids in place to facilitate communication and maintain awareness of the environment.

d. Allow the client to consume clear liquids up to the time of surgery: Clear liquids are typically restricted before surgery to prevent aspiration. This action may not align with standard

preoperative fasting guidelines.

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A nurse is collecting data on a client who is two days postoperative following creation of an ileal conduit. The nurse should report which of the following findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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