A nurse is planning postoperative care for a client who is scheduled for an ileal conduit procedure. The nurse should include which of the following in the client's plan of care? (Select all that apply).

Educate the client that hematuria is expected following the procedure.

Notify the provider immediately if mucus is present in the urine.

Monitor hourly urine output.

Apply skin barrier around the stoma site.

Maintain the client on a fluid restriction.

Answer and Explanation

Correct Answer : A,C,D

A. Hematuria is commonly expected following an ileal conduit procedure due to the surgical intervention in the urinary tract.
B. Mucus in the urine is a normal finding after an ileal conduit procedure because the ileum secretes mucus naturally; it does not require immediate notification of the provider unless there are other concerning symptoms.
C. Monitoring hourly urine output is crucial to ensure the patency of the urinary system and to detect any early signs of complications such as obstruction or leakage.
D. Applying a skin barrier around the stoma site is essential to protect the skin from the corrosive effects of urine and to prevent skin breakdown.
E. Fluid restriction is not typically required unless specifically indicated by the provider for other medical reasons; maintaining adequate hydration is important for the client's recovery and to ensure proper urine production.

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Correct Answer is A

Explanation

A. Yellow sclera
Yellow sclera indicates jaundice, which could be a sign of liver dysfunction. Both isoniazid and rifampin can cause hepatotoxicity, and monitoring for jaundice is crucial to ensure the safety of the client.

B. Increasing AST level
AST level is slightly elevated but remains in the upper range of normal. Continued monitoring is necessary but may not require immediate reporting unless liver function significantly deteriorates.

C. Weight loss
Weight loss is consistent with the client’s condition and does not necessarily require immediate reporting unless it is severe or unmanageable.

D. Mantoux test result
The Mantoux test result is negative, which may be expected in the early phase of tuberculosis treatment. It should be monitored over time.

E. Increasing ALT level
ALT is slightly elevated but still within normal limits, though it's essential to continue monitoring for trends.

F. Reddish-orange urine color
Reddish-orange urine is a known side effect of rifampin and does not typically require immediate reporting

A. Nosebleeds B. Temporary loss of smell C. Weight gain D. Mild hearing loss

Correct Answer is A

Explanation

A. Nosebleeds (epistaxis) are a common adverse effect of bevacizumab, as it can cause bleeding due to its anti-angiogenic properties.
B. Temporary loss of smell is not a recognized adverse effect of bevacizumab.
C. Weight gain is not typically associated with bevacizumab treatment.
D. Mild hearing loss is not a common adverse effect of bevacizumab.

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A nurse is planning postoperative care for a client who is scheduled for an ileal conduit procedure. The nurse should include which of the following in the client's plan of care? (Select all that apply).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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