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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Bradycardia: Atenolol is a beta-blocker that can slow down the heart rate, leading to
bradycardia. Monitoring the client for signs of bradycardia, such as dizziness, fatigue, or fainting, is important.
b. Anemia: Atenolol is not known to cause anemia. Monitoring for anemia is not a specific concern with this medication.
c. Hypokalemia: Atenolol is not associated with causing hypokalemia. However, beta-blockers in general may affect potassium levels indirectly.
d. Neutropenia: Atenolol is not typically associated with causing neutropenia. Monitoring for neutropenia is not a specific concern with this medication.
Correct Answer is D
Explanation
a. Turn the client so the cast will dry on all sides: While ensuring the cast is dry is important, the first priority following a surgical procedure is to assess neurovascular status to detect any
complications.
b. Remove the window and view the incision: Removing the window may compromise the cast's integrity, and the priority is to assess neurovascular status before inspecting the incision.
c. Medicate the client for pain: Pain management is important, but assessing neurovascular status is the initial priority to ensure there are no complications affecting circulation.
d. Perform neurovascular checks of the affected extremity: Neurovascular checks are the priority to detect any signs of impaired circulation or nerve function.
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