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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Encouraging the client to walk thirty minutes every day is a good practice but does not directly relate to the immediate outcome of managing chest pain.

Choice B reason: Monitoring blood glucose and blood pressure is part of ongoing management but is not a specific outcome related to exertional chest pain.

Choice C reason: Maintaining a daily blood pressure of less than 140/80 mm Hg is a specific and measurable outcome that can help manage symptoms of cardiovascular disease and prevent complications.

Choice D reason: A blood pressure reading of less than 160/90 mm Hg is less stringent than current guidelines suggest for optimal control in cardiovascular disease.

A. Tell the charge nurse about the prescribed placebo and refuse to administer it. B. Discuss ethical concerns about placebo use with the healthcare provider. C. Administer the placebo as prescribed when the client reports pain. D. Inform the client that the provider prescribed a placebo instead of pain medication.

Correct Answer is B

Explanation

Choice A reason: Telling the charge nurse and refusing to administer the placebo could be seen as insubordination and does not address the ethical concerns associated with placebo use.

Choice B reason: Discussing ethical concerns with the healthcare provider is the most appropriate action as it addresses the potential breach of patient trust and informed consent associated with placebo use.

Choice C reason: Administering the placebo as prescribed without addressing the ethical implications could compromise the nurse's professional integrity and the patient's trust.

Choice D reason: Informing the client that a placebo was prescribed could undermine the treatment plan and the provider-patient relationship, potentially causing harm to the client.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is developing a plan of care for a client who reports chest pain on exertion and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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