A nurse removes a client's Foley catheter and documents that the client urinates 4 hours later. Which of the following elements of postoperative care is the nurse performing?
Providing surgical site or wound care
Managing postoperative pain
Assisting with early ambulation
Monitoring urinary function
The Correct Answer is D
Choice A reason: The nurse is not providing surgical site or wound care by documenting urination.
Choice B reason: Managing postoperative pain is not directly related to monitoring the client's ability to urinate.
Choice C reason: Assisting with early ambulation does not pertain to the urinary function directly.
Choice D reason: Monitoring urinary function is part of postoperative care, especially after removal of a Foley catheter, to ensure the client is able to void normally.
Nursing Test Bank
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Maintaining the client in a left lateral position is not specifically required for peritoneal dialysis. Positioning may vary based on the individual's comfort and specific medical needs.
Choice B reason: While monitoring vital signs is important during any medical procedure, it is not an intervention that directly ensures proper dialysate exchange in peritoneal dialysis.
Choice C reason: Warming the dialysate solution prior to instillation is a standard practice in peritoneal dialysis. It helps to promote patient comfort and more efficient exchange of wastes and fluids.
Choice D reason: Placing the drainage bag above the level of the client's abdomen would impede gravity drainage, which is necessary for proper dialysate exchange. The drainage bag should be placed below the level of the client's abdomen.
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Correct Answer is C
Explanation
Choice A reason: Flatened neck veins would suggest dehydration rather than fluid overload.
Choice B reason: The return of skin to previous position when pinched indicates good skin turgor, not fluid overload.
Choice C reason: A significant weight gain in a short period, such as 5 lb since yesterday, is a classic sign of fluid overload.
Choice D reason: An oxygen saturation of 93% does not necessarily indicate fluid overload.
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