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

Explanation:

Bleach is an effective disinfectant for blood spills and is recommended by healthcare guidelines for its ability to kill a broad range of microorganisms, including bloodborne pathogens such as human immunodeficiency virus (HIV). To prepare a bleach solution, the nurse can mix 1-part bleach with 10 parts water. This diluted bleach solution can be used to clean and disinfect the overbed table surfaces that have been contaminated with blood.

A- Chlorhexidine is an antiseptic commonly used for skin preparation before invasive procedures, but it is not the ideal choice for disinfecting surfaces or objects after a blood spill.

B- Isopropyl alcohol is effective for disinfecting small surfaces, but it may not be as effective as bleach for blood spills, particularly in the context of bloodborne pathogens like HIV.

D- Hydrogen peroxide can be used as a disinfectant, but it may not be as effective as bleach in eliminating bloodborne pathogens from surfaces.

A. Limit the use of familiar objects. B. Make a schedule of daily tasks. C. Ask questions that require more than one answer. D. Have several family members visit daily.

Correct Answer is B

Explanation

B. Make a schedule for daily task.

Creating a schedule of daily tasks can provide structure and routine for individuals with Alzheimer's disease. This helps reduce confusion and frustration by providing a sense of familiarity and predictability. The schedule should be displayed in a visible location and include activities such as meals, personal care, medication administration, and any recreational or therapeutic activities. Following the schedule can help the client feel more oriented and decrease their frustration levels.

Limiting the use of familiar objects in (option A) should not be included because it may further increase frustration and disorientation. Familiar objects can provide comfort and a sense of security for individuals with Alzheimer's disease.

Asking questions that require more than one answer in (option C) should not be included because it can be overwhelming and confusing for someone with Alzheimer's disease. It is best to ask simple, straightforward questions to facilitate communication and comprehension.

Having several family members visit daily in (option D) should not be included because it may cause agitation and overstimulation for the client. It is important to maintain a calm and predictable environment, limiting the number of visitors and ensuring they are familiar to the client.
Therefore, the most appropriate intervention for the nurse to include is making a schedule of daily tasks (option B).

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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?