You arrive for your 7 a.m. shift on the urology unit and the night nurse gives a report on the following patients who will be under your care. Which one would you see first?
Mr. Dominic, newly admitted for evaluation of bladder cancer.
Mr. Bradford is 3 days post-radical prostatectomy for invasive bladder cancer. His urine output overnight was 1200 mL of blood-tinged urine. He did not sleep well and ambulated twice overnight complaining of gas pains.
Mr. Jennings had a TURBT (transurethral resection of bladder tumor) yesterday. He is complaining of bladder spasms. He had 3000 mL of bladder irrigation in overnight and 2950 mL out.
Ms. Griffiths, who had a cystectomy for bladder cancer 3 years ago, was admitted via the ER overnight with a complaint of severe hip pain and anorexia. Her lab tests were normal with the exception of elevated liver enzymes. After an initial dose of Dilaudid 1 mg, she reports her pain as 2 on a 0 to 10 scale and has slept fitfully overnight.
The Correct Answer is B
Choice A reason: Mr. Dominic's evaluation for bladder cancer is important, but there are no acute symptoms reported that require immediate attention over the other patients listed.
Choice B reason: Mr. Bradford's condition is the most concerning. He is 3 days post-radical prostatectomy with significant blood-tinged urine output and complaints of gas pains, which could indicate complications such as bleeding or infection that need immediate assessment.
Choice C reason: Mr. Jennings’ condition is stable with an almost equal in-and-out bladder irrigation, though bladder spasms should be addressed, it is not as immediately critical as Mr. Bradford's symptoms.
Choice D reason: Ms. Griffiths is stable with managed pain levels and normal lab results except for elevated liver enzymes, which do not present an immediate threat compared to Mr. Bradford's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Hepatitis is inflammation of the liver and does not directly cause biliary sludge. It can lead to liver damage and other complications, but not specifically biliary sludge.
Choice B reason: Bile stasis, or the stagnation of bile, leads to the formation of biliary sludge. When bile does not flow properly, it can thicken and form sludge, which consists of bile salts, cholesterol, and other substances.
Choice C reason: Ascites is the accumulation of fluid in the peritoneal cavity, typically due to liver disease, and does not cause biliary sludge.
Choice D reason: Biliary colic is pain caused by the obstruction of the bile ducts, often by gallstones, but it does not itself cause the formation of biliary sludge. Sludge can lead to biliary colic if it obstructs the bile ducts, but it is not a causative condition.
Correct Answer is A
Explanation
Choice A reason: Impaired skin integrity is a significant risk due to the constant exposure of the skin around the stoma to urine, which can lead to irritation and breakdown. Proper skin care and stoma care are essential to prevent complications.
Choice B reason: Disturbed body image is also a risk as the client adjusts to the physical changes and the presence of a stoma, which can impact self-esteem and body perception.
Choice C reason: Fluid volume deficit can occur if the client does not maintain adequate fluid intake or if there is significant leakage from the stoma. Monitoring fluid balance is crucial.
Choice D reason: Anxiety is common as clients adapt to managing a new ostomy, worrying about potential complications, and coping with changes in body function.
Choice E reason: Infection is a risk due to the exposure of the stoma and surrounding skin to bacteria from the urine. Proper hygiene and care are vital to prevent infections.
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