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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Instructing the client on the use of crutches is important but not as immediate as assessing for complications.
B. Performing neurovascular checks of the extremities is the most important action to identify complications such as compartment syndrome or impaired circulation.
C. Medicating the client for pain is important but secondary to monitoring for immediate postoperative complications.
D. Directing the client to perform exercises of the ankle and toes helps prevent complications but is not as critical as performing neurovascular assessments.
Correct Answer is ["A","C","D"]
Explanation
A. Myoglobin is an early biomarker for myocardial injury and can be used for initial detection of myocardial infarction. However, it is less specific than troponins.
B. Plasma low-density lipoproteins (LDL) are associated with cardiovascular risk but are not used to diagnose an acute myocardial infarction.
C. Troponin T is a highly specific biomarker for myocardial infarction and is used to confirm the diagnosis of an MI.
D. Troponin I is another highly specific biomarker for myocardial infarction and is used to confirm the diagnosis of an MI.
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