A nurse is collecting data on a client who is two days postoperative following creation of an ileal conduit. The nurse should report which of the following findings?

Urine in the drainage appliance

Feces in the drainage appliance

Mild edema of the stoma

Redness of the stoma

Answer and Explanation

The Correct Answer is B

a. Urine in the drainage appliance: The presence of urine in the drainage appliance is expected in a client with an ileal conduit, as this is the route for urine to exit the body.

b. Feces in the drainage appliance: An ileal conduit is created for urinary diversion, and feces

should not be present in the drainage appliance. This finding could indicate a complication and should be reported.

c. Mild edema of the stoma: Mild edema of the stoma may be expected in the early postoperative period and may not require immediate reporting unless it worsens.

d. Redness of the stoma: Some redness is normal around a stoma, and it may not require immediate reporting unless there are signs of infection or worsening inflammation.

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Correct Answer is B

Explanation

a. “I will wait 10 min between each inhalation.”: There is no need to wait 10 minutes between

inhalations of albuterol. The usual recommendation is to wait 1-2 minutes if a second inhalation is needed.

b. “I will hold my breath at least 10 seconds after inhaling the medication.”: Holding the breath for at least 10 seconds after inhaling helps ensure that the medication reaches the lower airways and is absorbed effectively.

c. “I will tilt my head forward while inhaling the medication.”: Tilted head position is not necessary for using an inhaler; a proper inhalation technique is more critical.

d. “I will hold the inhaler with my non-dominant hand.”: The hand used to hold the inhaler is not as crucial as proper inhalation technique, but using the dominant hand may be more comfortable for most individuals.

A. Potassium level of 3.0 mEq/L B. Heart rate of 66/min C. BP of 132/82 mm Hg D. Digoxin level of 1.2 ng/ml

Correct Answer is A

Explanation

a. Potassium level of 3.0 mEq/L: Hypokalemia is a potential adverse effect of digoxin, and a

potassium level of 3.0 mEq/L is below the normal range. Low potassium levels can increase the risk of digoxin toxicity.

b. Heart rate of 66/min: A heart rate of 66/min is within the normal range. Digoxin is used to

treat conditions like atrial fibrillation, and the heart rate should be within an appropriate range for the client's condition.

c. BP of 132/82 mm Hg: Blood pressure within the normal range does not require immediate reporting in the context of digoxin administration.

d. Digoxin level of 1.2 ng/ml: The digoxin level of 1.2 ng/ml is within the therapeutic range, and it does not require immediate reporting.

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A nurse is collecting data on a client who is two days postoperative following creation of an ileal conduit. The nurse should report which of the following findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing discharge teaching with a client following an episode of statusasthmaticus. The client has a prescription for two inhalations from an albuterol metered-dose inhaler. Which of the following statements by the client indicates an understanding of theteaching?

Correct Answer is B

Explanation

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Correct Answer is A

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