A nurse is caring for a patient after urinary diversion surgery. What postoperative nursing assessment is the priority?
Level of fluid intake
Keep the bed flat
Position on the left side
Bowel sounds
The Correct Answer is D
A. Level of fluid intake: While monitoring fluid intake is important, bowel sounds are more critical immediately after surgery to detect potential paralytic ileus or other complications.
B. Keep the bed flat: Postoperative positioning depends on the type of surgery and is not universally necessary.
C. Position on the left side: There is no specific need to position the patient on the left side postoperatively unless otherwise indicated.
D. Bowel sounds: Assessing bowel sounds is crucial to monitor for postoperative complications such as ileus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Facial twitching: Facial twitching is unrelated to fluid retention and may indicate neuromuscular or electrolyte imbalances.
B. Periorbital edema: Periorbital (around the eyes) edema is a common sign of fluid retention, particularly in renal impairment.
C. Rash on cheeks and neck: A rash is not associated with fluid retention and may indicate other conditions such as allergies or lupus.
D. Broken blood vessels around the nose: This is unrelated to fluid retention and may result from trauma or alcohol use.
Correct Answer is A
Explanation
A. Bleeding from the kidney: Dark red urine often indicates bleeding from the upper urinary tract, including the kidneys, due to trauma, infection, or stones.
B. Dehydration: Dehydration typically causes concentrated urine with a darker yellow color, not red.
C. Bleeding from the lower urinary tract: Bleeding from the lower urinary tract usually results in bright red urine, not dark red urine.
D. Excessive red meat in the patient's diet: While dietary factors can influence urine color (e.g., beets), red meat does not cause dark red urine.
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