A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery?
Intestinal obstruction
Folate deficiency
Malabsorption of fat
Fluid and electrolyte imbalance
The Correct Answer is D
Choice A Reason: This is incorrect because intestinal obstruction is not a common complication of ileostomy surgery. An ileostomy is a surgical opening in the abdomen that connects the end of the small intestine (ileum) to a pouch or bag outside the body. This allows stool to bypass the colon and rectum. Intestinal obstruction can occur if there is a blockage or narrowing in any part of the digestive tract, but it is more likely to affect the colon than the ileum.
Choice B Reason: This is incorrect because folate deficiency is not a common complication of ileostomy surgery. Folate is a vitamin that is essential for DNA synthesis and cell division. Folate is mainly absorbed in the jejunum, which is the middle part of the small intestine. An ileostomy does not affect the jejunum, so it does not interfere with folate absorption.
Choice C Reason: This is incorrect because malabsorption of fat is not a common complication of ileostomy surgery. Fat is digested and absorbed in both the small and large intestine. An ileostomy does not affect fat digestion, but it may reduce fat absorption by decreasing the transit time and surface area of the intestine. However, this is usually not significant enough to cause malabsorption symptoms.
Choice D Reason: This is correct because fluid and electrolyte imbalance is a common complication of ileostomy surgery. Fluid and electrolytes are mainly absorbed in the colon, which is bypassed by an ileostomy. This can result in increased fluid and electrolyte loss through stool, especially sodium and potassium. This can lead to dehydration, hypotension, weakness, cramps, or arrhythmias.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A Reason: This is correct because melanoma is a type of skin cancer that arises from melanocytes, which are cells that produce pigment. Melanoma lesions are often irregular in shape and color, and may have different shades of brown or black.
Choice B Reason: This is correct because melanoma is a very aggressive and invasive type of skin cancer that can spread quickly to other parts of the body through the blood or lymphatic system. Melanoma has a high mortality rate if not detected and treated early.
Choice C Reason: This is incorrect because warm and red skin around a lesion may indicate inflammation or infection, but not necessarily melanoma. Melanoma lesions may have other signs, such as bleeding, itching, or ulceration.
Choice D Reason: This is correct because melanoma is associated with exposure to ultraviolet (UV) radiation from sunlight or artificial sources, such as tanning beds. UV radiation can damage the DNA of melanocytes and cause them to grow abnormally.
Choice E Reason: This is incorrect because melanoma lesions are usually not painful unless they are ulcerated or infected. Pain may be a sign of other types of skin conditions, such as burns, blisters, or cuts.
Correct Answer is ["A","B","D"]
Explanation
Choice A Reason: This is a correct choice. Standing next to the client when speaking is an action that the nurse should plan to take, as it helps the client hear better and see the nurse's facial expressions and lip movements. The nurse should also speak clearly and slowly, use simple words and sentences, and avoid covering their mouth.
Choice B Reason: This is a correct choice. Guiding the client away from background noise is an action that the nurse should plan to take, as it reduces distractions and interference with hearing. The nurse should also choose a well-lit and quiet place for communication and turn off any unnecessary devices or appliances.
Choice C Reason: This is an incorrect choice. Providing a copy of the instructions printed in Braille is not an action that the nurse should plan to take, as it is not helpful for clients with hearing loss. Braille is a system of raised dots that represents letters and numbers for people who are blind or visually impaired. The nurse should provide a copy of the instructions printed in large font or use pictures or diagrams to supplement verbal information.
Choice D Reason: This is a correct choice. Repeating any phrases that the client misunderstands is an action that the nurse should plan to take, as it ensures comprehension and clarification of important information. The nurse should also ask open-ended questions, encourage feedback, and summarize key points at the end of the conversation.
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