A nurse is discussing the plan of care of a client who is 4 hr postoperative and has a urostomy with assistive personnel.
Which of the following statements should the nurse include in the discussion?
We will keep the client's fluid intake restricted until he is free of pain.
Expect the stoma to appear pale until healing is complete.
We need to check the client's urine output every hour.
Expect the diet’s urine to contain clots for the first 24 hours.
The Correct Answer is C
Checking the client's urine output regularly is important to monitor kidney function, hydration status, and the proper functioning of the urostomy. This information helps assess the client's overall condition and ensures that urine is flowing adequately. Any significant changes in urine output should be reported to the healthcare team.
Restricting the client's fluid intake until they are free of pain in (option A) is not necessary to be included in the discussion unless specifically ordered by the healthcare provider. Adequate hydration is important for promoting healing and preventing complications.
Expecting the stoma to appear pale until healing is complete in (option B) is not necessary to be included in the discussion. A healthy stoma should have a pink or reddish appearance, indicating good blood supply. A pale stoma may suggest poor blood flow, and this should be assessed and reported to the healthcare provider.
Expecting the client's urine to contain clots for the first 24 hours in (option D) is not included in the discussion after urostomy surgery. Urine containing clots may indicate bleeding or other complications, and this should be promptly evaluated by the healthcare team.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Explanation
C. Initiate contact precautions
Clostridium difficile is a bacterium that causes diarrhea and can be easily transmitted from person to person. Contact precautions are necessary to prevent the spread of the infection. This includes wearing gloves and a gown when providing direct care to the child, ensuring proper hand hygiene, and implementing proper disinfection protocols for the environment.
The other options are not necessary or specific to the care of a child with Clostridium difficile:
Using an N95 respirator in (option A) is not necessary for the care of a child with Clostridium difficile. Respirators are typically used for airborne precautions, which are not indicated for this specific infection.
Instructing the parents to avoid bringing fresh flowers into the room in (option)is not specific to the care of a child with Clostridium difficile. While it is generally recommended to minimize potential sources of contamination in healthcare settings, this particular instruction is not specific to this infection.
Placing the child in a room with a HEPA filtration system in (option D) is not necessary for the care of a child with Clostridium difficile. HEPA filtration systems are typically used for airborne precautions, which are not indicated for this specific infection.
Correct Answer is A
Explanation
Correct answer: A
Option A is correct.In this scenario, the social worker is likely involved in the client's care plan and needs the medical information to provide appropriate support services.Involuntary commitment: In cases of involuntary commitment, there might be a court order allowing for information sharing to ensure the client's well-being..
Option B is incorrect because sharing client information with a client's employer is generally not appropriate without the client's explicit consent. Confidentiality must be maintained, and any concerns about safety due to substance use should be discussed with the client and appropriate healthcare professionals.
Option C is incorrect.Sharing information with a nurse from another unit after a client commits suicide is generally not appropriate unless: there is a specific reason for sharing, such as identifying potential risks to other clients, the minimum amount of information necessary is shared and the sharing complies with HIPAA (Health Insurance Portability and Accountability Act) regulations.
Option D is incorrect because sharing client information with a client's partner after the client reports intimate partner abuse could potentially compromise the client's safety. It is crucial to follow specific protocols and laws related to reporting abuse while ensuring the client's confidentiality and well-being.
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