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. Infection: While infection can cause localized redness and swelling, deep vein thrombosis (DVT) is a more likely cause given the client's immobility and other risk factors.
B. Fat emboli: Fat emboli typically occur after trauma or orthopedic procedures, and their presentation is less likely in this scenario.
C. Pulmonary embolism: While a pulmonary embolism is a potential complication of DVT, it presents with symptoms such as dyspnea, chest pain, and tachypnea, rather than localized redness and swelling in the calf.
D. Deep vein thrombosis: This condition, characterized by redness and swelling in the affected limb, is common in immobile patients and those with dehydration, making it the most likely cause of the client's symptoms.

A. Provide protective undergarments for the client. B. Encourage increased fluid intake for 24 hours. C. Evaluate the client's response to bladder training efforts. D. Obtain a clean, voided urine specimen for analysis.

Correct Answer is D

Explanation

A. Providing protective undergarments may be necessary as a temporary measure to manage urinary incontinence, but it does not address the underlying cause. It should not be the initial intervention.
B. Encouraging increased fluid intake may exacerbate urinary incontinence if the cause is related to an overactive bladder or other urinary tract issues. It's important to determine the cause before recommending changes in fluid intake.
C. Evaluating the client's response to bladder training efforts is a relevant intervention for urinary incontinence, but it assumes that bladder training is appropriate for the client's condition. Before initiating bladder training, it's essential to assess the client's condition through proper evaluation.
D. Obtaining a clean, voided urine specimen for analysis is the priority intervention. It allows for diagnostic testing to identify potential causes of urinary incontinence, such as urinary tract
infections, urinary retention, or other underlying medical conditions. Once the cause is determined, appropriate interventions can be implemented, which may include bladder training, medication, or other treatments.

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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?

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