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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2500"]
Explanation
500MLS of the solution= 25,000units 50mls = 5025000/500
=2500units
Therefore, the client receives 2500 units per hour.
Correct Answer is ["B","C"]
Explanation
A. Urinalysis: While urinalysis can provide information about urinary tract infections, it is not directly related to monitoring the effectiveness of antibiotic treatment for a respiratory tract
infection.
B. White blood cell (WBC count: Monitoring WBC count can help assess the body's response to infection. A decrease in WBC count can indicate improvement in the infection.
C. Sputum culture and sensitivity: Monitoring sputum culture and sensitivity helps determine if the antibiotic is targeting the specific pathogen causing the respiratory tract infection and if the chosen antibiotic is effective against it.
D. Serum potassium: Monitoring serum potassium levels is important with certain antibiotics,
but it is not directly related to evaluating the effectiveness of antibiotic treatment for a respiratory tract infection.
E. Red blood cell (RBC count: RBC count is not typically monitored to evaluate the effectiveness of antibiotic treatment for a respiratory tract infection.
F. Blood urea nitrogen (BUN): BUN levels are not directly related to assessing the effectiveness of antibiotic treatment for a respiratory tract infection.
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