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. Request an order for an antiemetic - Checking vital signs is the priority before administering any medication. Antiemetics may be considered later, but the nurse needs to assess the client's overall condition first.

B. Request a dietary consult - Assessing vital signs comes before consulting for dietary issues.

The priority is to determine the client's immediate physiological status.

C. Check the client’s vital signs - This is the correct first action as it helps to evaluate the client's cardiovascular status, especially considering the potential toxicity of digoxin in the setting of

nausea and refusal of breakfast.

D. Suggest that the client rests before eating the meal - While rest may be beneficial, assessing vital signs takes precedence to rule out any acute cardiovascular compromise.

A. Weight gain B. Constipation C. Frequent mood changes D. Sensitivity to cold

Correct Answer is C

Explanation

a. Weight gain: Hyperthyroidism is more commonly associated with weight loss due to increased metabolism.

b. Constipation: Hyperthyroidism is more likely to cause diarrhea or increased bowel movements.

c. Frequent mood changes: Hyperthyroidism can lead to mood swings, irritability, and anxiety.

d. Sensitivity to cold: Sensitivity to cold is more commonly associated with hypothyroidism, not hyperthyroidism.

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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

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