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 A

Explanation

Promoting trust involves actions that build a sense of trust and rapport between the nurse and the client. In this scenario, the nurse recognizes the client's basic need for food and responds to it promptly and compassionately. By interrupting the bath to address the client's hunger, the nurse demonstrates attentiveness and care, which helps establish trust between the nurse and the client.

Countertransference refers to the nurse's emotional reaction or response to the client, which may be based on the nurse's personal experiences or unresolved issues. It does not apply to the nurse's action of obtaining a meal for the client.

Veracity refers to truthfulness and honesty. While the nurse's action can be seen as honest and caring, it does not specifically relate to the concept of veracity.

Boundary crossing refers to a situation where the nurse exceeds the established professional boundaries with the client. In this scenario, the nurse's action of obtaining a meal for the client can be seen as a minor deviation from the routine care but is not considered a significant boundary crossing.

A. "I will apply antibiotic ointment to my baby's penis." B. “I will apply pressure with gauze if I see bleeding." C. “I will wipe away yellow crusts that form around the incision." D. "I will make sure that my baby's diaper is applied snugly."

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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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?