A client with bladder cancer had surgical placement of a ureteroileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?

Liquid brown drainage from stoma.

Stomal output of 40 mL in the last hour.

Red edematous stomal appearance.

Mucous strings floating in the drainage.

Answer and Explanation

The Correct Answer is A

A. Liquid brown drainage from the stoma is abnormal and could indicate bowel content leakage, suggesting a potential connection between the bowel and the conduit or possible infection. This is a critical finding and should be reported immediately.

- B: A stomal output of 40 mL in the last hour is within normal limits postoperatively, as urine production can vary and this amount does not suggest acute complications.

C. A red and edematous stomal appearance is normal in the immediate postoperative period and indicates adequate blood supply to the stoma.

- D: Mucous strings in the drainage are normal because mucus is produced by the intestinal lining, which is now part of the urinary diversion. This is an expected finding and not a cause for immediate concern.

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Correct Answer is D

Explanation

A. Elevating the head of the bed to a 45-degree angle is important for clients with obstructive sleep apnea (OSA to help prevent airway obstruction during sleep. However, applying the
positive airway pressure device is a more immediate and direct intervention to ensure adequate breathing.
B. Removing dentures or other oral appliances may be necessary for comfort and safety during sleep, but it's not directly related to managing obstructive sleep apnea in this scenario.
C. Lifting and locking the side rails in place is a standard safety measure in healthcare settings but does not address the client's obstructive sleep apnea or ensure adequate ventilation.
D. Applying the client's positive airway pressure (PAP) device is the most important intervention before leaving the client. The PAP device helps maintain an open airway by delivering
continuous positive airway pressure, which is crucial for managing obstructive sleep apnea and preventing complications such as apnea episodes during sleep.

A. Assist the client to recall everyone possibly exposed since the onset of symptoms. B. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus. C. Place the nasal swab specimen for COVID-19 directly into a biohazard bag. D. Move the client to a private room, keep the door closed, and initiate droplet precautions.

Correct Answer is D

Explanation

A. Assisting the client to recall everyone possibly exposed since the onset of symptoms is important for contact tracing but is not the most immediate action to take.
B. Teaching the client to wear a mask, hand wash, and social distance to prevent spreading the virus is important for infection control but does not address the immediate need to prevent
potential transmission to others in the clinic setting.
C. Placing the nasal swab specimen for COVID-19 directly into a biohazard bag is appropriate for specimen handling but does not address the need for immediate infection control measures for the client and others in the clinic setting.
D. Moving the client to a private room, keeping the door closed, and initiating droplet precautions is the most important action to take to prevent potential transmission of COVID-19 to others in the clinic setting, given the client's symptoms and recent travel history.

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A client with bladder cancer had surgical placement of a ureteroileostomy (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 places an opioid patch on the chest of a client with intractable pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client?

Correct Answer is D

Explanation

Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

Correct Answer is D

Explanation

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