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.

Answer and Explanation

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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Correct Answer is C

Explanation

This response allows the nurse to express genuine interest in the client's perspective and opens up a dialogue to understand the client's concerns or reasons for refusing to learn how to self-administer insulin. It provides an opportunity for the client to express their fears, doubts, or any barriers they may have. By actively listening to the client, the nurse can better address their concerns and provide appropriate education and support tailored to their individual needs.

The other options may come across as confrontational, judgmental, or unhelpful in establishing a therapeutic relationship with the client. It is important for the nurse to approach the situation with empathy, respect, and a non-judgmental attitude to foster effective communication and promote the client's engagement in their own care.

A. Use one client identifier before administering medication B. Read medication labels twice before administration. C. Document the administration of medications after all assigned clients have been medicated. D. Check the clients' allergy bands with each medication administration.

Correct Answer is D

Explanation

The correct answer is D. Checking the clients' allergy bands with each medication administration is a safety measure to prevent adverse drug reactions. According to the Healthline website, "Always ask patient about allergies, types of reactions, and severity of reactions" before giving any medication.

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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?

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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?