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 A

Explanation

A. Acknowledging the parent's emotions with a supportive statement like, "This must be a very difficult time for you," validates their feelings and encourages open communication.
B. While surgery can help manage myelomeningocele, a full recovery is not always possible, as the condition may lead to lifelong complications. This response may give false reassurance.
C. Asking why the parent feels at fault could unintentionally reinforce feelings of guilt rather than providing comfort and support.
D. While it is true that the parent did nothing wrong, this response may dismiss their feelings rather than helping them process their emotions.

A. Ask the client to take short, rapid breaths. B. Instruct the client in pursed lip breathing. C. Increase oxygen to three L/minute. D. Have the client breathe into a paper bag.

Correct Answer is B

Explanation

A. Ask the client to take short, rapid breaths: This can increase respiratory rate and may exacerbate the client's shortness of breath.
B. Instruct the client in pursed lip breathing: Pursed lip breathing can help improve gas exchange and reduce dyspnea by slowing down the client's respiratory rate and increasing oxygenation.
C. Increase oxygen to three L/minute: Increasing oxygen without assessing the client's oxygen saturation may lead to oxygen toxicity and is not indicated without further assessment.
D. Have the client breathe into a paper bag: This intervention is not appropriate for a client with chronic obstructive lung disease experiencing shortness of breath. It is typically used for clients experiencing hyperventilation.

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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 parent of a child born with a myelomeningocele asks the nurse, "What did I do to deserve this?" Which response is most helpful?

Correct Answer is A

Explanation

A client with chronic obstructive lung disease who is receiving oxygen at 1.5 L/minute by nasal cannula, is currently short of breath. Which action should the nurse take?

Correct Answer is B

Explanation

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