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. Administering aspirin may be appropriate for suspected ischemic stroke; however, it should not be done without confirmation of diagnosis and evaluation by the stroke team.
B. Initiating pneumatic compression devices is not the priority in this situation. Acute assessment and management of the suspected stroke take precedence.
C. Placing an indwelling urinary catheter and measuring strict intake and output may be necessary for ongoing care but is not the priority when the client is presenting with symptoms suggestive of a stroke.
D. Notifying the stroke team to assist with acute assessment and management is the priority intervention. Time is crucial in the management of stroke, and early intervention can help minimize neurological damage and improve outcomes.

A. Maintain sequential compression devices while in bed. B. Teach client to use incentive spirometer every 2 hours while awake. C. Assess pain level and medicate PRN as prescribed. D. Remove urinary catheter as soon as possible and encourage voiding. E. Administer low molecular weight heparin as prescribed.

Correct Answer is ["B","D"]

Explanation

SCDs are effective for preventing DVT but are not directly related to infection prevention. The focus here is more on preventing respiratory and urinary infections.

B. Teaching the client to use an incentive spirometer every 2 hours while awake helps prevent
atelectasis and pneumonia by promoting deep breathing and lung expansion, reducing the risk of respiratory infections.
C. Assessing pain level and medicating PRN as prescribed is important for postoperative comfort but is not directly related to reducing the risk of infection.
D. Removing the urinary catheter as soon as possible and encouraging voiding helps reduce the risk of urinary tract infections, which are common in clients with prolonged catheter use.
E. Low molecular weight heparin helps prevent blood clots, reducing the risk of thrombosis, which can increase the risk of postoperative complications, including infections.

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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

Correct Answer is D

Explanation

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Correct Answer is ["B","D"]

Explanation

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