A nurse observes that a client's ileal conduit stoma is dark bluish in the immediate postoperative period. Which of these actions should the nurse take?
a. Chart the observation.
b. Have the client assume a semi-Fowler's position.
c. Remove the pouch, and make the pouch opening larger.
d. Notify the health care provider immediately.
D
A dark bluish color in a client's ileal conduit stoma in the immediate postoperative period could indicate a lack of blood supply, and the health care provider should be notified immediately.
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A patient with type 1 diabetes mellitus is being discharged home after an episode of diabetic ketoacidosis (DKA). What should the nurse most emphasize in discharge teaching?
A) Insulin therapy may be discontinued after several months. B) The patient needs supplemental insulin even when not eating. C) Blood sugar is best regulated by use of long-lasting insulin preparations. D) Blood sugar can be regulated by diet if the patient is very careful.
The nurse identifies the nursing diagnosis Urinary Incontinence (Total) in an older adult patient admitted after a stroke. Urinary Incontinence places the patient at risk for which complication?
a. Skin breakdown b. Urinary tract infection c. Bowel incontinence d. Renal calculi
While assessing a child the nurse finds hepatomegaly. The nurse is aware that this condition is most associated with which of the following?
a. congestive heart failure c. maternal alcoholism b. congenital heart defects d. prematurity
When providing care to an elderly patient living with her son and daughter-in-law, the nurse assesses the patient and family. This is an aspect of
A) Patient-centered nursing interventions B) Outcome criteria for care C) Family-centered care D) Age-related nursing care