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 B

Explanation

A. Instruct in effective techniques to cleanse the glans penis: While hygiene education may be important, the client's symptoms suggest a urinary issue that needs further assessment.
B. Palpate the client's suprapubic area for distention: These symptoms are consistent with urinary retention, and palpating the suprapubic area can help assess for bladder distention.
C. Advise the client to maintain a voiding diary for one week: While a voiding diary can provide valuable information, the client's symptoms indicate a need for immediate assessment and
intervention.

D. Obtain a urine specimen for culture and sensitivity: While obtaining a urine specimen is important, it may not directly address the immediate concern of possible urinary retention

A. Teach a family member to administer eye drops. B. Encourage deep breathing and coughing exercises. C. Provide an eye shield to be worn while sleeping. D. Obtain vital signs every 2 hours during hospitalization.

Correct Answer is C

Explanation

A. Teaching a family member to administer eye drops may be appropriate for some clients undergoing eye surgery, but it is not specifically indicated for retinal detachment repair.
B. Encouraging deep breathing and coughing exercises is important for preventing respiratory complications but is not directly related to postoperative care for retinal detachment repair.
C. Providing an eye shield to be worn while sleeping is important to protect the eye and prevent inadvertent trauma during the vulnerable postoperative period. It helps promote healing and
prevents further injury to the eye.
D. Obtaining vital signs every 2 hours during hospitalization is a general nursing intervention but is not specific to the postoperative care of a client undergoing retinal detachment repair.

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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

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Correct Answer is C

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