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 B
Explanation
Applying pressure with gauze helps to control bleeding and promote clotting. The other statements are not accurate or appropriate for circumcision care: "I will apply antibiotic ointment to my baby's penis" is not recommended for Plastibell circumcision. The use of antibiotic ointment is not typically necessary or recommended unless specifically advised by the healthcare provider.
"I will wipe away yellow crusts that form around the incision" should not be done as it may disrupt the healing process. Yellow crusts are a normal part of the healing process and should be left undisturbed.
"I will make sure that my baby's diaper is applied snugly" is unrelated to circumcision care. While proper diapering is important for maintaining hygiene, it does not specifically address the care of the circumcision site.
Correct Answer is C
Explanation
Fontanels are soft spots on an infant's skull where the bones have not yet fused together. The anterior fontanel, located at the front of the head, typically closes between 12 to 18 months of age. The posterior fontanel, located at the back of the head, usually closes by 2 to 3 months of age.
The other findings mentioned are typical developmental milestones for a 4-month-old infant:
- Rolling from back to abdomen: By 4 months of age, it is expected that infants can roll from their back to their abdomen. This is a normal developmental milestone.
- Moves objects to mouth: At 4 months, infants begin to develop hand-eye coordination and the ability to reach for objects. Bringing objects to the mouth is a typical behavior at this age as infants explore their environment.
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