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 A
Explanation
Choice A reason: Understanding the reason for taking aspirin is crucial because it could be for a chronic condition that requires antiplatelet action, which ibuprofen does not provide. Aspirin is often prescribed for its antiplatelet effect to prevent blood clots, while ibuprofen is primarily used for pain and inflammation.
Choice B reason: While the dosage of ibuprofen is important, it is secondary to understanding the purpose of the aspirin therapy. Overdosing on ibuprofen can lead to serious side effects, but the immediate risk of stopping aspirin without a suitable substitute could be more critical.
Choice C reason: Assessing the amount of pain control is important to evaluate the effectiveness of ibuprofen as a substitute for aspirin. However, this does not address the potential risks associated with the cessation of aspirin, especially if it was prescribed for cardiovascular reasons.
Choice D reason: The presence of gastric pain could indicate an adverse reaction to ibuprofen, which is known to cause gastrointestinal issues. However, this information is not as immediately necessary as understanding the reason for aspirin therapy, which could have significant implications for the client's health.
Correct Answer is C
Explanation
Choice A reason: While pneumatic compression devices are used for DVT prevention, they are not the immediate intervention for suspected stroke.
Choice B reason: Placing an indwelling urinary catheter is not the first-line intervention for a patient with suspected stroke symptoms.
Choice C reason: Notifying the stroke team is the most appropriate action as the patient's symptoms suggest a possible stroke, requiring urgent evaluation and management.
Choice D reason: Aspirin may be used in the management of stroke, but only after a stroke has been confirmed and not as an immediate intervention.
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