The nurse is caring for a client that has undergone a radical cystectomy and has an ileal conduit. Which post-operative assessment finding should the nurse immediately report to the physician?

slight bleeding from stoma when changing the appliance

urine output of 2 mL/hr

Deep red, moist stoma

Musky, bluish stoma

Answer and Explanation

The Correct Answer is D

A. Slight bleeding from stoma when changing the appliance: Some slight bleeding can be normal when changing the appliance, especially if the stoma is new and there is irritation. However, persistent or heavy bleeding should be reported.

B. Urine output of 2 ml/hr: A urine output of 2 ml/hr is extremely low and should be investigated, but it is not immediately life-threatening. However, if the low output persists, it may indicate a problem such as dehydration, obstruction, or kidney issues.

C. Deep red, moist stoma: A deep red, moist stoma is a normal finding postoperatively. This is indicative of healthy tissue, as the stoma should be red and moist, similar to the inside of the mouth.

D. Musky, bluish stoma: A musky or bluish stoma is concerning as it can indicate inadequate blood flow (ischemia) to the stoma. This requires immediate attention because it could suggest that the stoma is not receiving adequate oxygen and nutrients, which may lead to necrosis and the need for surgical intervention.

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Correct Answer is B

Explanation

A. Respiratory acidosis: Respiratory acidosis would be characterized by a low pH and high PaCO2. In this case, the pH is elevated (7.51), and PaCO2 is low (28 mmHg), which indicates respiratory alkalosis, not acidosis.

B. Respiratory alkalosis: Respiratory alkalosis occurs when there is a decrease in PaCO2 (below 35 mmHg) due to hyperventilation. The low PaCO2 (28 mmHg) and elevated pH (7.51) are indicative of respiratory alkalosis, where the body is losing too much CO2.

C. Metabolic alkalosis: While the pH is elevated, the bicarbonate (HCO3) level is within normal range (24 mEq/L), which suggests that the cause of the alkalosis is not metabolic in nature. Respiratory alkalosis is the more appropriate interpretation.

D. Metabolic acidosis: Metabolic acidosis would be associated with a low pH and a low bicarbonate (HCO3) level. In this case, the pH is elevated and HCO3 is normal, so metabolic acidosis is not the correct interpretation.

A. Administer a Flu and Pneumovax immunization IM. B. Restrict visitation of family and friends who have colds, flu, or infections. C. Assist the client with appropriate hygiene measures. D. Report neutrophil levels of 2000 mm3-2500 mm3 to the PCP E. Obtain vital signs including temperature and pulse oximetry every & hours

Correct Answer is ["B","C","E"]

Explanation

A. Administer a Flu and Pneumovax immunization IM: In acute myelocytic leukemia, where the immune system is compromised, administering live vaccines or vaccines during active treatment is not recommended as their immune system may not be able to mount an adequate response.

B. Restrict visitation of family and friends who have colds, flu, or infections: Limiting exposure to people who have infections is crucial. Their immune system is often suppressed due to both the disease and treatment, making the client highly susceptible to infections.

C. Assist the client with appropriate hygiene measures: Proper hygiene is essential for reducing the risk of infections in immunocompromised clients. This includes handwashing and maintaining cleanliness to minimize the risk of infections.

D. Report neutrophil levels of 2000/mm3-2500/mm3 to the PCP: Neutrophil levels of 2000–2500/mm3 are within acceptable range, so there is no immediate need to report this to the healthcare provider. A critical neutrophil count is <1000/mm3, where infection risk is high.

E. Obtain vital signs including temperature and pulse oximetry every 4 hours: Monitoring vital signs, especially temperature, is essential in clients with AML due to their heightened risk of infection. Fever can indicate the onset of infection, so regular monitoring is critical.

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The nurse is caring for a client that has undergone a radical cystectomy and has an ileal conduit. Which post-operative assessment finding should the nurse immediately report to the physician?

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Naxlex Comprehensive Predictor Exams

The client's arterial blood gases reveal the following results: pH 7.51. Pa02 80 mmHg, PaCO2 28 mmHg. HCO3 24 mEq/L 02 saturation 92%. The nurse interprets this blood gas result as: PH7.35-7.45 PCO2 35-45mm Hg HCO3 22-26 m/l Sa02 95-100% PaO2 80-100mm Hg

Correct Answer is B

Explanation

The nurse is caring for a client diagnosed with acute myelocytic leukemia (AML). A nursing diagnosis of Risk for Infection has been made. What nursing intervention(s) should the nurse employ in the care of this client? (Select all that apply)

Correct Answer is ["B","C","E"]

Explanation

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