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 C
Explanation
Choice A Reason: This is incorrect because drawing with crayons may be too childish or frustrating for a client with moderate Alzheimer's. Crayons may also pose a choking hazard or cause messes. The nurse should provide activities that are suitable for the client's cognitive and functional level, as well as their interests and preferences.
Choice B Reason: This is incorrect because dangling ribbons or a mobile may be too stimulating or confusing for a client with moderate Alzheimer's. These items may also trigger agitation or wandering behaviors. The nurse should provide activities that are calming and familiar for the client.
Choice C Reason: This is correct because listening to music, watching TV, or videos can be enjoyable and beneficial for a client with moderate Alzheimer's. Music can evoke memories, emotions, and positive responses. TV or videos can provide entertainment, education, and socialization. The nurse should choose music, TV shows, or videos that are appropriate and meaningful for the client.
Choice D Reason: This is incorrect because board games may be too complex or challenging for a client with moderate Alzheimer's. Board games may require memory, concentration, logic, or strategy skills that the client may have lost. The nurse should provide activities that are simple and easy for the client to follow.
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because a blister-like pustule on the face that oozes clear fluid may indicate impetigo, which is a bacterial skin infection, not basal cell carcinoma. Basal cell carcinoma is a type of skin cancer that arises from the basal layer of the epidermis, which is the outermost layer of the skin. Basal cell carcinoma lesions are usually not blistered or pustular, but rather smooth, shiny, or waxy.
Choice B Reason: This is incorrect because a dark brown lesion that is flat may indicate a mole, which is a benign growth of melanocytes, which are cells that produce pigment, not basal cell carcinoma. Basal cell carcinoma lesions are usually not dark brown or flat, but rather flesh-colored, pink, or red, and may have a raised or indented center.
Choice C Reason: This is correct because a small scaly, dry lesion on the elbow may indicate basal cell carcinoma. Basal cell carcinoma lesions are often small, scaly, and dry, and may bleed or crust over. They can occur anywhere on the body, but are more common on areas that are exposed to the sun, such as the face, neck, arms, or legs.
Choice D Reason: This is incorrect because location on the top of the head where exposed frequently to sunlight may indicate squamous cell carcinoma, which is another type of skin cancer that arises from the squamous layer of the epidermis, not basal cell carcinoma. Squamous cell carcinoma lesions are usually rough, scaly, or crusted, and may have a firm or hard texture. They can also occur anywhere on the body, but are more common on areas that are exposed to the sun.
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