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 C

Explanation

A. The side-lying position is not appropriate for paracentesis because it does not allow optimal access to the abdomen and can make fluid removal more difficult.

B. The supine position is also not suitable for paracentesis, as it may not allow for proper drainage and can increase the risk of respiratory compromise, especially in clients with large volumes of ascitic fluid.

C. High-Fowler’s position is correct because it helps pool the ascitic fluid in the lower abdomen, making it easier to access and drain during the procedure. This position also helps improve breathing by relieving pressure on the diaphragm caused by the ascites.

D. The leaning forward position is not appropriate for paracentesis, as it can be uncomfortable and does not provide optimal access to the abdominal cavity for fluid removal.

A. Ecchymosis B. Skin integrity C. Temperature D. Color E. Sensation

Correct Answer is ["B","C","D","E"]

Explanation

A. Ecchymosis indicates bruising but is not a primary parameter for assessing neurovascular status.

B. Skin integrity is important to monitor for any signs of breakdown or infection.

C. Temperature helps assess for adequate blood flow and potential complications.

D. Color of the extremity indicates blood flow and can show signs of compromised circulation.

E. Sensation checks for nerve damage or impaired circulation.

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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 is preparing a client who is scheduled to undergo a paracentesis. Into which of the following positions should the nurse assist the client for this procedure?

Correct Answer is C

Explanation

A nurse is caring for a client who is postoperative following an open reduction internal fixation (ORIF) of a femur fracture. Which of the following parameters should the nurse include in the evaluation of the neurovascular status of the client's affected extremity? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

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