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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 A

Explanation

A. The right hemisphere controls judgment, reasoning, and impulse control, so clients may exhibit impulsive behaviors after a right-sided stroke.

B. Deficits in the right visual field would occur with a left hemisphere stroke, not a right hemisphere stroke.

C. Difficulty discriminating words and letters is typically associated with left hemisphere damage.

D. Motor retardation is not a specific finding associated with right hemisphere strokes; these often involve impulsive behavior and left-sided neglect.

A. Check the client for a fecal impaction. B. Examine the client for areas of skin breakdown. C. Place the client in a sitting position. D. Check the client's bladder for distention.

Correct Answer is C

Explanation

A. Checking for fecal impaction can help relieve the cause of autonomic dysreflexia but should be done after positioning the client.

B. Skin breakdown can trigger autonomic dysreflexia, but the immediate priority is to lower blood pressure by sitting the client up.

C. Placing the client in a sitting position helps lower blood pressure, which is the immediate concern in autonomic dysreflexia.

D. Checking for bladder distention is essential to find the trigger, but positioning comes first to manage the acute blood pressure elevation.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

Correct Answer is A

Explanation

A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

Á nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?

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A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?

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