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

"My baby will receive the rotavirus immunization orally." - This statement is correct. The rotavirus vaccine is administered orally, typically as drops or as an oral suspension. It is important for the guardian to follow the specific instructions provided by the healthcare provider for the administration of the rotavirus vaccine.

"I should not feed my baby anything for 2 hours prior to an immunization." - This statement is incorrect. It is not necessary to withhold feeding prior to immunizations. In fact, it is generally recommended to feed the baby before the immunization to help provide comfort during the procedure.

"My baby will receive three doses of the meningococcal immunization before kindergarten." This statement is incorrect. The number of doses and the schedule for each immunization may vary. The guardian should consult with the healthcare provider or refer to the immunization schedule for the specific recommendations regarding the meningococcal immunization.

"I should expect my baby to have a high fever for 24 hours after an immunization." - This statement is not entirely accurate. While it is common for infants to experience mild side effects such as a low-grade fever after immunizations, a high fever is less common. The guardian should be aware of the potential side effects and contact the healthcare provider if they have concerns about their baby's reaction to the immunization.

A. Believes that his brother's death will be reversible B. Regresses to an earlier developmental level C. Alienates himself from his peers D. Believes his bad behavior is causing his brother's death

Correct Answer is D

Explanation

It is common for school-age children to exhibit magical thinking and believe that their actions or thoughts have the power to cause events, including the illness or death of a loved one. Therefore, it would be expected for the school-age brother of a child with terminal cancer to have thoughts or beliefs that his own behavior is causing his brother's death.

It is important for the nurse to provide age-appropriate education and support to help the brother understand the nature of the illness and address any misconceptions or feelings of guilt.

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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

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Correct Answer is C

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Correct Answer is D

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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?