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 : B,C,D,E

Choice A rationale
Anxiety, while a valid concern, is not directly a risk associated with the physical complications of an ileal conduit. However, it can be an emotional response to the surgery and the changes it brings.

Choice B rationale
Impaired skin integrity is a significant risk for clients with an ileal conduit due to the potential for irritation from the stoma appliance and the risk of skin breakdown around the stoma site.

Choice C rationale
Infection is a risk due to the potential for bacteria to enter through the stoma or for urinary tract infections to develop, given the changes in the urinary system's structure and function.

Choice D rationale
Fluid volume deficit is a risk for clients with an ileal conduit because of the potential for increased fluid loss through the stoma, necessitating careful monitoring and management of fluid intake and output.

Choice E rationale
Disturbed body image is a risk due to the physical changes and the presence of a stoma, which can affect the client's perception of their body and self-image.

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Correct Answer is A

Explanation

Choice A rationale
In the case of hyperkalemia, which can cause fatal cardiac arrhythmias, the most immediate nursing action is to place the patient on a cardiac monitor. This allows for continuous monitoring of the heart's rhythm and immediate detection of any life-threatening changes, which is crucial for timely intervention.

Choice B rationale
Inserting a urinary retention catheter may be necessary for managing oliguria, but it is not the most urgent action when compared to the potential cardiac risks associated with hyperkalemia.

Choice C rationale
Administering spironolactone, a potassium-sparing diuretic, could be part of the treatment for hyperkalemia, but it is not the first action to take. Spironolactone works more slowly and does not address the immediate risk of cardiac arrhythmias.

Choice D rationale
Epoetin alfa (Epogen) is used to treat anemia, particularly in chronic kidney disease, to increase red blood cell production. However, it does not have an immediate effect and is not the priority in the presence of hyperkalemia and potential cardiac complications.

A. Increasing hemoglobin level B. Decreasing serum amylase level C. Falling serum bilirubin level D. Increasing serum alkaline phosphatase level

Correct Answer is B

Explanation

Choice A reason: An increasing hemoglobin level does not indicate the resolution of acute pancreatitis. Hemoglobin levels can fluctuate due to various factors, including hydration status and blood loss, but are not directly related to the resolution of pancreatitis.

Choice B reason:A decreasing serum amylase level is indicative of the resolution of acute pancreatitis. Amylase is an enzyme that helps digest carbohydrates and is released in large amounts when the pancreas is inflamed. As the inflammation resolves, amylase levels decrease.

Choice C reason: A falling serum bilirubin level may indicate improvement in liver function but is not a specific indicator of the resolution of acute pancreatitis. Bilirubin levels can be affected by conditions other than pancreatitis, such as bile duct obstruction or liver disease.

Choice D reason:An increasing serum alkaline phosphatase level is generally associated with bile duct obstruction or bone disease and does not indicate the resolution of acute pancreatitis. This enzyme is found in several tissues throughout the body, including the liver and bones.

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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

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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