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 D

Explanation

A. Increasing the rate to 250 mL/hr is not appropriate as it could lead to fluid overload or worsen the client’s condition.

B. Slowing the rate to 20 mL/hr may be too low for maintaining adequate hydration or treatment needs in the context of a head injury.

C. Slowing the rate to 50 mL/hr is not indicated unless there is a specific reason to decrease the fluid rate based on clinical conditions, which is not stated here.

D. Continuing the rate at 125 mL/hr is appropriate for maintaining the current IV fluid regimen unless there are specific orders or conditions that require a change.

A. First-degree AV block B. Atrial fibrillation C. Sinus tachycardia D. Sinus bradycardia

Correct Answer is B

Explanation

A. First-degree AV block shows a prolonged PR interval but not necessarily an irregular heart rate or a significant pulse deficit.

B. Atrial fibrillation is characterized by a rapid and irregular heart rate with a significant pulse deficit, which aligns with the client's symptoms.

C. Sinus tachycardia presents with a rapid but regular heart rate, not irregular palpitations.

D. Sinus bradycardia shows a slow heart rate and is not associated with an irregular heart rate or significant pulse deficit.

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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

A nurse in the emergency department is caring for a client who sustained a head injury. The nurse notes the client's IV fluids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse?

Correct Answer is D

Explanation

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

Correct Answer is B

Explanation

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