A client with bladder cancer had surgical placement of a ureter ileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?
Mucous strings floating in the drainage.
Red edematous stomal appearance.
Stomal output of 40 mL in the last hour.
Liquid brown drainage from the stoma.
The Correct Answer is D
Choice A reason: Mucous strings in the drainage are normal as mucus is produced by the intestine, which is now part of the urinary diversion.
Choice B reason: A red edematous stomal appearance can be expected postoperatively as part of the normal healing process.
Choice C reason: Stomal output of 40 mL in the last hour is within the normal range for postoperative urinary output.
Choice D reason: Liquid brown drainage from the stoma could indicate a problem such as an infection or bowel content leakage and should be reported immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A broad-spectrum antibiotic is not indicated for Addison's disease unless there is a concurrent bacterial infection.
Choice B reason: Regular insulin is used to lower blood glucose levels, which are not elevated in this case.
Choice C reason: Potassium chloride would not be prescribed as the potassium level is already high.
Choice D reason: Hydrocortisone is anticipated because it is a corticosteroid replacement therapy, which is essential for a patient with Addison's disease experiencing an adrenal crisis.
Correct Answer is C
Explanation
Choice A reason: Obtaining vital signs every 2 hours is standard postoperative care but does not specifically address the needs of a client recovering from retinal detachment surgery.
Choice B reason: While deep breathing and coughing exercises are important postoperative interventions, they are not specific to the care of a client after retinal detachment surgery.
Choice C reason: Providing an eye shield for sleep helps to protect the eye from accidental rubbing or pressure, which is critical after retinal surgery.
Choice D reason: Teaching a family member to administer eye drops is important for ongoing care but is not as immediately critical as protecting the eye from injury.
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