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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a. Position the client flat in bed: This position may increase pressure on the abdomen and exacerbate ascites. The head of the bed should be elevated to enhance respiratory function.
b. Weigh the client weekly: Weighing the client daily is more appropriate to monitor fluid retention and assess the effectiveness of interventions.
c. Medicate the client with acetaminophen for discomfort: While acetaminophen can be used for pain relief, its use should be monitored closely due to the potential for liver toxicity in clients with cirrhosis.
d. Measure the client’s abdominal girth every 8 hours: Monitoring abdominal girth is crucial for assessing the degree of ascites and evaluating the effectiveness of interventions.
Correct Answer is A
Explanation
a. A client taking furosemide for chronic hypertension: Furosemide is a loop diuretic that can
lead to hypokalemia, which increases the risk of digoxin toxicity, as hypokalemia potentiates the effects of digoxin on the heart.
b. A client taking a potassium supplement twice a day: Potassium supplementation reduces the risk of digoxin toxicity, as hypokalemia is a risk factor for toxicity.
c. A client taking aluminum hydroxide for gastric upset: Aluminum hydroxide is an antacid and does not significantly affect digoxin levels.
d. A client taking chlorpropamide for type 2 diabetes mellitus: Chlorpropamide is an oral hypoglycemic agent and does not significantly affect digoxin levels.
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