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 C

Explanation

a. Hyperactive bowel sounds: Shock is more likely to be associated with decreased bowel sounds rather than hyperactive bowel sounds.

b. Increased urine output: In the early stages of shock, there may be an increase in urine output as the body attempts to compensate. However, as shock progresses, renal perfusion decreases,

leading to decreased urine output.

c. Hypotension: Hypotension is a key indicator of shock. In shock, there is insufficient blood flow to meet the body's oxygen and nutrient needs, resulting in a drop in blood pressure.

d. Bradycardia: Shock typically leads to an increased heart rate (tachycardia) as the body tries to compensate for decreased cardiac output. Bradycardia is not a typical finding in the early stages of shock.

A. Prothrombin time (PT) B. Platelet count C. White blood cell count (WBC) D. Activated partial thromboplastin time (aPTT)

Correct Answer is A

Explanation

a. Prothrombin time (PT): Warfarin affects the extrinsic pathway of the coagulation cascade, and PT is the primary diagnostic test used to monitor the therapeutic effect of warfarin. It measures

the time it takes for blood to clot.

b. Platelet count: Platelet count assesses the number of platelets in the blood and is not specifically used to monitor the effect of warfarin.

c. White blood cell count (WBC): WBC count assesses the number of white blood cells and is not specifically used to monitor the effect of warfarin.

d. Activated partial thromboplastin time (aPTT): While aPTT is a valuable test for monitoring the therapeutic effect of heparin, it is not the primary test for warfarin. Warfarin primarily affects the extrinsic pathway, and PT is more appropriate for monitoring its effects.

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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

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