A nurse is planning postoperative care for a client who is scheduled for an ileal conduit procedure. The nurse should include which of the following in the client's plan of care? (Select all that apply).
Educate the client that hematuria is expected following the procedure.
Notify the provider immediately if mucus is present in the urine.
Monitor hourly urine output.
Apply skin barrier around the stoma site.
Maintain the client on a fluid restriction.
Correct Answer : A,C,D
A. Hematuria is commonly expected following an ileal conduit procedure due to the surgical intervention in the urinary tract.
B. Mucus in the urine is a normal finding after an ileal conduit procedure because the ileum secretes mucus naturally; it does not require immediate notification of the provider unless there are other concerning symptoms.
C. Monitoring hourly urine output is crucial to ensure the patency of the urinary system and to detect any early signs of complications such as obstruction or leakage.
D. Applying a skin barrier around the stoma site is essential to protect the skin from the corrosive effects of urine and to prevent skin breakdown.
E. Fluid restriction is not typically required unless specifically indicated by the provider for other medical reasons; maintaining adequate hydration is important for the client's recovery and to ensure proper urine production.
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Related Questions
Correct Answer is B
Explanation
A. Bounding peripheral pulses are more associated with fluid overload, not diabetes insipidus.
B. Tachycardia can occur in diabetes insipidus due to dehydration and fluid loss.
C. Hypertension is not a typical finding; clients with diabetes insipidus often have low blood pressure due to fluid loss.
D. Hyperglycemia is associated with diabetes mellitus, not diabetes insipidus.
Correct Answer is []
Explanation
Condition:
A. Transfusion-associated circulatory overload (TACO)
Rationale: The client’s symptoms—dyspnea, restlessness, crackles in the lungs, jugular vein distension, and elevated blood pressure—are consistent with TACO, a condition resulting from excessive fluid volume during a blood transfusion.
Actions to Take:
C. Administer furosemide
Rationale: Furosemide is a diuretic that helps reduce fluid overload, which is a key issue in TACO.
B. Administer diphenhydramine
Rationale: Although not the primary treatment for TACO, diphenhydramine can help manage symptoms if there is a mild allergic reaction contributing to the situation.
Parameters to Monitor:
A. Intake and output
Rationale: Monitoring intake and output helps assess fluid balance and effectiveness of treatment for TACO.
D. Weight
Rationale: Weight monitoring helps assess fluid overload and effectiveness of diuretic therapy
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