The practical nurse (PN) is assisting with preparation of a client for fecal diversion surgery. While inserting an indwelling urinary catheter, the client asks if the surgical opening will be visible.
Which action should the PN implement?
Review the client's expectations of elimination after surgery.
Verify that the client had nothing by mouth (NPO) for the past 24 hours.
Ask the client if he finished the bowel sterilization prescription.
Determine if this is the first indwelling catheter the client has had.
The Correct Answer is A
This is the best action for the PN to implement because it addresses the client's question and provides an opportunity to educate the client about the fecal diversion surgery and its outcomes. The PN should review the type, location, and appearance of the surgical opening (stoma) and explain how it will affect the client's elimination and body image.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choicec. Ask the parents to explain what they understand about the child’s diagnosis.
Choice A rationale:
While it is important to support the parents’ decisions, this choice does not address the need for accurate information and understanding about the condition and its management.
Choice B rationale:
Hypospadias does not typically resolve on its own, and delaying surgery can lead to complications such as difficulty with urination and sexual function later in life.
Choice C rationale:
Asking the parents to explain what they understand about the child’s diagnosis ensures that they have accurate information and can make an informed decision about the timing of surgery.This approach also allows the nurse to correct any misconceptions and provide necessary education.
Choice D rationale:
Delaying surgery for hypospadias can lead to complications, including issues with urination and sexual function.It is important to address these potential risks with the parents.
Correct Answer is B
Explanation
The correct answer is Choice B. Report the finding to the charge nurse. Choice A rationale:
Checking for kinks in the drainage tubing is an important troubleshooting step if there is a sudden decrease or absence of urine output. However, in this case, the PN's concern is the presence of thick red fluid with clots in the urine drainage. This finding indicates potential bleeding, which requires immediate attention and reporting.
Choice B rationale:
Reporting the finding to the charge nurse is the correct action. The presence of thick red fluid with clots in the urine suggests significant bleeding after the transurethral resection of the prostate (TURP) surgery. It is crucial to inform the charge nurse or the healthcare provider promptly so that appropriate interventions can be initiated to address the bleeding.
Choice C rationale:
Stopping the irrigation solution immediately may not be within the PN's scope of practice unless explicitly instructed by the healthcare provider. Moreover, abruptly stopping the irrigation may lead to complications, and it is essential to involve the charge nurse or healthcare provider in making this decision.
Choice D rationale:
Observing the drainage again in one hour is not appropriate in this situation. The presence of thick red fluid with clots in the urine drainage is an urgent concern that requires immediate action, not a wait-and-see approach.
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