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A nurse is preforming 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.)

Maintain the client on fluid restriction

Educate the client that hematuria is expected following the procedure

Notify the provider immediately if mucus is present in the urine

Apply skin barrier to the stoma site

Monitor hourly urine output

Answer and Explanation

Correct Answer : B,D,E

A. Fluid restriction is generally not indicated; maintaining hydration is important to ensure adequate urine output.

B. Hematuria is expected postoperatively due to surgical manipulation and should be explained to the client.

C. Mucus in the urine is common with an ileal conduit since the conduit is created using a portion of the intestine, which naturally produces mucus.

D. Applying a skin barrier protects the skin around the stoma site from irritation and breakdown.

E. Monitoring hourly urine output helps assess kidney function and the patency of the conduit.

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

Explanation

A. An increase in hemoglobin does not indicate infection; it may indicate dehydration or improved oxygenation.

B. The absence of ketones in urine is not related to infection status.

C. An increase in band neutrophils, known as a "left shift," is a sign of infection as the body releases immature neutrophils in response to infection.

D. A negative leukocyte esterase in urine indicates no presence of white blood cells in the urine, suggesting no urinary infection.

E. An elevated erythrocyte sedimentation rate (ESR) is a nonspecific marker of inflammation and can indicate infection or other inflammatory processes.

A. Wrap the residual limb with an elastic bandage in a figure-eight configuration. B. Wrap the residual limb with an elastic bandage in a proximal-to-distal direction. C. Remove the elastic bandage and re-wrap the residual limb once a day. D. Secure the elastic bandage to the lowest joint.

Correct Answer is A

Explanation

A. Wrapping the residual limb in a figure-eight configuration provides compression and support, shaping the limb for prosthesis fitting, and promoting proper circulation.

B. Wrapping in a proximal-to-distal direction can restrict blood flow and does not provide the appropriate support needed for prosthetic shaping.

C. The bandage should be rewrapped more frequently than once a day to maintain compression and limb shape.

D. Securing the bandage at the lowest joint is inadequate as it may allow loosening and improper shaping of the residual limb.

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A nurse is preforming 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

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A nurse is reviewing the laboratory results of a client who is postoperative. Which of the following laboratory findings should the nurse identify as an indication of a postoperative infection? (Select All that Apply.)

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

Explanation

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Explanation

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