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 B

Explanation

a. Neck vein distention: Neck vein distention may indicate fluid overload, but it is not a direct measure of fluid losses.

b. Body weight: Monitoring body weight before and after hemodialysis provides a direct

measure of fluid losses. Hemodialysis removes excess fluid, and changes in body weight reflect fluid balance.

c. Abdominal girth: Abdominal girth may be affected by fluid accumulation but is not a direct measure of fluid losses during hemodialysis.

d. Blood pressure: While blood pressure may be influenced by fluid status, it is not a specific measure of fluid losses during hemodialysis. Body weight is a more direct indicator of fluid removal.

A. Droplet precautions B. Airborne precautions C. Standard precautions D. Contact precautions

Correct Answer is C

Explanation

a. Droplet precautions: Droplet precautions are used for diseases that are transmitted by

respiratory droplets, such as influenza or pneumonia. HIV is not transmitted through respiratory droplets.

b. Airborne precautions: Airborne precautions are used for diseases that are transmitted through the airborne route, such as tuberculosis. HIV is not transmitted through the airborne route.

c. Standard precautions: Standard precautions are used for the care of all patients, regardless of their diagnosis. These precautions include hand hygiene, use of personal protective equipment (PPE) as needed, and safe injection practices.

d. Contact precautions: Contact precautions are used for diseases that are spread by direct or indirect contact, such as methicillin-resistant Staphylococcus aureus (MRSA). HIV is not

transmitted through contact with intact skin.

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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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Correct Answer is B

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Correct Answer is C

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