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
Regular physical exercise has been shown to promote better sleep. Engaging in daily exercise can help regulate the sleep-wake cycle, promote relaxation, reduce anxiety and stress, and increase overall sleep quality. It is important to note that exercise should ideally be done earlier in the day, at least a few hours before bedtime, as exercising too close to bedtime may actually have a stimulating effect and make it harder to fall asleep.
The other options listed are not the most appropriate recommendations for addressing difficulty in falling asleep:
- "Sleep longer hours on the weekend." This suggestion may disrupt the client's sleep routine and can lead to inconsistent sleep patterns throughout the week, potentially making it more challenging to fall asleep on subsequent nights.
- "Keep the television volume low while you are trying to fall asleep." It is generally recommended to create a sleep-friendly environment, which includes reducing external stimuli like noise, light, and electronic devices in the bedroom. However, watching television right before bedtime can interfere with sleep as the bright light and stimulating content can keep the mind awake.
- "Remain in bed until you fall asleep." This recommendation may contribute to increased frustration and anxiety if the client is unable to fall asleep quickly. It is generally advised to practice good sleep hygiene, which includes getting out of bed if unable to fall asleep after a reasonable amount of time and engaging in a relaxing activity until feeling sleepy again.
Correct Answer is D
Explanation
This response acknowledges the son's exhaustion and offers a constructive solution by suggesting respite care. Respite care provides temporary relief to caregivers by arranging for someone else to take over caregiving responsibilities for a specific period of time.
It allows caregivers to have a break and take care of their own physical and emotional well-being. By providing information about respite care, the nurse is offering support and resources to help alleviate the son's fatigue while ensuring that the mother's care needs are still met.
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