Which assessment by a nurse caring for an immediate postoperative patient with an ileal conduit should be reported or receive attention immediately?
Mucus present in the urine
Distended abdomen
Small amount of blood in the drainage
Lack of bowel sounds
The Correct Answer is B
Rationale:
A. Mucus in the urine is expected in patients with an ileal conduit because the urinary diversion uses a segment of the ileum, which naturally secretes mucus. This is not an immediate concern.
B. Abdominal distention in an immediate postoperative patient may indicate bowel obstruction, ileus, or internal bleeding. These conditions can become life-threatening if not addressed promptly, so the nurse should report and intervene immediately.
C. A small amount of blood in the urine or drainage is expected in the early postoperative period due to surgical manipulation of the ureters and ileum. It is monitored but not an emergency.
D. Absent bowel sounds are common immediately after abdominal surgery due to temporary postoperative ileus. While it should be monitored, it is not immediately life-threatening unless accompanied by severe pain, distention, or vomiting.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Evisceration refers to internal organs protruding through a surgical incision. While serious, it is usually visible at the surgical site and does not explain systemic signs such as fever, tachycardia, and rigid abdomen.
B. Localized inflammation may cause redness, tenderness, or mild discomfort, but it would not typically produce a rigid abdomen, high fever, and elevated pulse and respirations.
C. An obstruction can cause abdominal distention, nausea, vomiting, and decreased stoma output, but a rigid abdomen and systemic signs like fever and tachycardia suggest a more severe intra-abdominal infection.
D. The patient’s rigid abdomen, tachycardia (pulse 120 bpm), tachypnea (respirations 28/min), and fever (101°F) are classic signs of peritonitis, a life-threatening infection of the abdominal cavity. This can occur post-operatively due to leakage from the stoma, bowel perforation, or infection. Prompt recognition and immediate medical intervention are critical, often requiring antibiotics and possible surgical management.
Correct Answer is A
Explanation
Rationale:
A. An ileostomy diverts intestinal contents from the ileum (small intestine) to an external stoma, bypassing the colon. The colon normally absorbs water and electrolytes from stool. Without this absorption, patients are at risk for excessive fluid and electrolyte loss, which can lead to deficient fluid volume if not carefully monitored and managed.
B. While some patients may have decreased appetite after surgery, anorexia is not the primary reason for fluid volume risk. The main concern is fluid loss through the stoma, not decreased intake.
C. Blood loss during ileostomy surgery is generally moderate and controlled, and it is not the primary factor leading to postoperative fluid volume deficit. Fluid imbalance in these patients is primarily due to intestinal fluid loss.
D. Patients are typically encouraged to maintain adequate hydration postoperatively. Fluid intake is not routinely restricted, and doing so would increase the risk of deficient fluid volume.
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