A nurse assesses a client with bladder cancer who is recovering from a complete cystectomy with ileal conduit. Which assessment finding should alert the nurse to urgently contact the health care provider?
a. The ileostomy is draining blood-tinged urine.
b. There is serous sanguineous drainage present on the surgical dressing.
c. The ileostomy stoma is pale and cyanotic in appearance.
d. Oxygen saturations are 92% on room air.
ANS: C
A pale or cyanotic stoma indicates impaired circulation to the stoma and must be treated to prevent necrosis. Blood-tinged urine and serous sanguineous drainage are expected after this type of surgery. Oxygen saturation of 92% on room air is at the low limit of normal.
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Effective communication skills or nursing actions when caring for the patient with dementia is/are: (SELECT ALL ANSWERS THAT APPLY)
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