A nurse is developing a plan of care for a client who has a new ileal conduit. Which of the following should the nurse include as risks for the client? (Select all that apply.)

Anxiety

Impaired skin integrity

Infection

Fluid volume deficit

Disturbed body image

Answer and Explanation

Correct Answer : A,B,C,E

Choice A reason: A new ileal conduit is a permanent life change that requires the client to learn complex self-care skills. The uncertainty regarding stoma management, fear of appliance leakage in public, and the lifestyle adjustments required often lead to significant anxiety. The nurse must address these psychological stressors during the initial postoperative period to promote successful adaptation.

Choice B reason: The continuous drainage of urine from the stoma creates a high risk for peristomal skin breakdown. Urine is caustic to the skin, and moisture trapped under the skin barrier can lead to maceration, dermatitis, or fungal infections. Maintaining a secure, well-fitted appliance and assessing the skin frequently are essential nursing interventions for this risk.

Choice C reason: Surgical creation of an ileal conduit involves bowel resection and ureteral implantation, increasing the risk for peritonitis or wound infection. Furthermore, since the conduit is a direct pathway to the kidneys without a sphincter, the client is at lifelong risk for ascending urinary tract infections or pyelonephritis requiring vigilant monitoring.

Choice D reason: While postoperative patients require fluid monitoring, an ileal conduit does not typically cause a chronic fluid volume deficit. Unlike an ileostomy, where significant water and electrolytes are lost through liquid stool, the ileal conduit simply transports urine. Unless there is excessive surgical bleeding or unrelated dehydration, this is not a primary risk.

Choice E reason: The permanent diversion of urine to an external pouch on the abdomen significantly alters the client's physical appearance and "normal" elimination process. Concerns regarding sexual function, clothing choices, and the presence of a stoma frequently lead to a disturbed body image, necessitating supportive counseling and referral to an ostomy nurse.

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Correct Answer is C

Explanation

Choice A rationale
Monitoring calcium levels is important after administering calcium gluconate IV, but it is not the primary indicator of the medication's effectiveness in treating hyperkalemia. Calcium gluconate is used in hyperkalemia to stabilize the heart muscle, not to correct calcium levels.

Choice B rationale
Neurologic status may be affected by hyperkalemia, but changes in neurologic status are not the most direct measure of calcium gluconate's effectiveness. The medication's primary role is to address cardiac risks associated with high potassium levels.

Choice C rationale
Cardiac rhythm is the most critical aspect to monitor after administering calcium gluconate for hyperkalemia. Hyperkalemia can cause life-threatening cardiac dysrhythmias, and calcium gluconate works by stabilizing the cardiac membrane, thus the effectiveness of the treatment is directly reflected in the stabilization of the cardiac rhythm.

Choice D rationale
While urine volume can indicate kidney function and might indirectly reflect changes in potassium levels, it is not the direct measure of calcium gluconate's effectiveness in the emergency treatment of hyperkalemia.

A. Hypertension B. Frequency C. Flank pain D. Neck pain E. Costovertebral tenderness F. Urgency

Correct Answer is ["B","C","E","F"]

Explanation

Choice A rationale
Hypertension is not a typical manifestation of pyelonephritis. While it can be present due to other underlying conditions, it is not directly related to pyelonephritis.

Choice B rationale
Frequency, or the need to urinate more often, is a common symptom of pyelonephritis as the infection can irritate the bladder and urinary tract.

Choice C rationale
Flank pain is a classic symptom of pyelonephritis. It is usually located on the side of the affected kidney and can be quite severe.

Choice D rationale
Neck pain is not associated with pyelonephritis. It is more likely related to musculoskeletal issues or other non-urinary tract conditions.

Choice E rationale
Costovertebral tenderness, which is tenderness felt on tapping the back where the ribs meet the spine, is indicative of kidney infection and is expected in pyelonephritis.

Choice F rationale
Urgency, or a sudden, strong need to urinate, is another symptom of pyelonephritis due to inflammation and irritation in the urinary system.

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A nurse is developing a plan of care for a client who has a new ileal conduit. Which of the following should the nurse include as risks for the client? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient who has is hospitalized with hyperkalemia. Which information will the nurse monitor to evaluate the effectiveness of the acute glomerulonephritis prescribed calcium gluconate IV?

Correct Answer is C

Explanation

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Correct Answer is ["B","C","E","F"]

Explanation

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