October 27, 2011

NCLEX-RN Practice Question Challenge!

Correct Answer: 3

1: Not of most concern. The intestinal mucosa is very fragile and it is common that it bleeds at this stage during changing of the appliance or due to the collection pouch not fitting properly
2: Of definite concern but not most, interventions would include: decreasing frequency of pouch changing, using a non-karaya skin barrier (urine erodes karaya), leaving skin open to air when possible as when changing the pouch, promoting acid urine (alkaline urine irritates the skin) and using Nystatin cream or powder if yeast infection
3: CORRECT | Fever and pain (along with abdominal rigidity) are indications of peritonitis. Urine may have entered the peritoneal cavity from the anastomosis site leaking or from separation of the ureter from the ileal segment (the conduit). There may have been spillage from the intestine during the surgery, physician should be notified at once. Requires immediate medical attention
4: Not of concern at this time, due to the bowel manipulation and resection. There will be no peristalsis for several days. Patient will remain NPO and has IV lines and an NG tube in place until peristalsis is reestablished. Bowel sounds do need to be assessed