A client has returned from the recovery room after undergoing a urinary diversion. The nurse should monitor the stoma for:
1. blanching.
2. erosion of skin around the stoma.
3. decreased urine output.
4. blood in the urine.
Answer: 1
1. Blanching of the stoma indicates a disruption in the blood supply.
2. The nurse would assess the skin around the stoma, but the question asks about the stoma.
3. Urine output is not relevant to the stoma.
4. Hematuria is not relevant to the stoma.
You might also like to view...
A patient is admitted to the ICU with a history of general malaise for two weeks. A nurse does the initial assessment and suspects leukemia. What are the signs and symptoms that will identify if this patient has leukemia? Select all that apply
A) Anemia, general malaise, bleeding B) Tachycardia, hypotension and shortness of breath C) Hypertension, very high fever, and low heart rate D) Bone pain, headache, vomiting, papilledema
When caring for a client with progressive macular degeneration, which teaching measure is primary for client safety?
A) Patch the affected eye. B) Turn head side to side when walking. C) Avoid bending over. D) Avoid straining the eyes.
A 26-year-old woman has experienced debilitating pelvic pain accompanied by uterine bleeding for many months and has finally received a diagnosis of uterine fibroids. The nurse is aware that this patient desires to have children in the future
Consequently, the nurse should expect that the patient's health care provider will likely recommend what treatment? A) Hysterectomy B) Myomectomy C) Radiation therapy D) Oral antiviral medication
The nurse is caring for a patient diagnosed with acute hepatic dysfunction. Which of the following clinical findings would indicate to the nurse that the patient is developing hepatorenal syndrome?
1. decrease in PT 2. blood pressure 136/88 mm Hg 3. glomerular filtration rate reduced from 58% to 36% 4. urine output 45 cc/hour