A nurse is caring for a patient after urinary diversion surgery. What postoperative nursing assessment is the priority?
Level of fluid intake
Keep the bed flat
Position on the left side
Bowel sounds
The Correct Answer is D
A. Level of fluid intake: While monitoring fluid intake is important, bowel sounds are more critical immediately after surgery to detect potential paralytic ileus or other complications.
B. Keep the bed flat: Postoperative positioning depends on the type of surgery and is not universally necessary.
C. Position on the left side: There is no specific need to position the patient on the left side postoperatively unless otherwise indicated.
D. Bowel sounds: Assessing bowel sounds is crucial to monitor for postoperative complications such as ileus.
Nursing Test Bank
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Related Questions
Correct Answer is D
Explanation
A. Inject the ordered amount of heparin into the fistula: Heparin is not used to treat occlusion in a fistula without specific orders or a proper diagnostic workup.
B. Apply warm compresses and lower the arm below the heart level: These interventions are not effective for resolving an absent trill in an AV fistula.
C. Send the patient to dialysis for remedy: The absence of a trill requires immediate assessment before considering dialysis treatment.
D. Report to the charge nurse that the fistula is occluded: An absent trill may indicate occlusion or thrombosis of the AV fistula, which requires urgent evaluation and intervention.
Correct Answer is A
Explanation
A. Flat plate: A flat plate of the abdomen (plain X-ray) is safe and does not involve contrast dye.
B. Intravenous pyelogram: This procedure involves the use of contrast dye, which is nephrotoxic and contraindicated in patients with renal insufficiency or diabetes mellitus due to the risk of worsening kidney function.
C. Ultrasonography: Ultrasounds do not involve dye or radiation and are safe for patients with renal insufficiency or diabetes.
D. Renal scan: While renal scans can involve radioactive material, they are generally safer for assessing kidney function in these patients compared to an IV pyelogram.
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