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.

Answer and Explanation

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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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.

A. Instruct the client to avoid movement of the affected leg. B. Position the lower extremities so that they are touching. C. Prevent hip flexion of the affected extremity. D. Ensure that the client's heels are touching the bed.

Correct Answer is C

Explanation

A. Instruct the client to avoid movement of the affected leg is not practical for postoperative care; the goal is to manage movement safely, not completely avoid it.

B. Position the lower extremities so that they are touching is incorrect; the legs should be kept in abduction to prevent dislocation.

C. Prevent hip flexion of the affected extremity is essential to prevent dislocation of the hip joint. Keeping the hip in a neutral or slightly extended position helps achieve this.

D. Ensure that the client's heels are touching the bed is not a relevant intervention for preventing complications after a hip arthroplasty.

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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).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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