A nurse is discussing the plan of care of a client who is 4 hr postoperative and has a urostomy with assistive personnel.
Which of the following statements should the nurse include in the discussion?
We will keep the client's fluid intake restricted until he is free of pain.
Expect the stoma to appear pale until healing is complete.
We need to check the client's urine output every hour.
Expect the diet’s urine to contain clots for the first 24 hours.
The Correct Answer is C
Checking the client's urine output regularly is important to monitor kidney function, hydration status, and the proper functioning of the urostomy. This information helps assess the client's overall condition and ensures that urine is flowing adequately. Any significant changes in urine output should be reported to the healthcare team.
Restricting the client's fluid intake until they are free of pain in (option A) is not necessary to be included in the discussion unless specifically ordered by the healthcare provider. Adequate hydration is important for promoting healing and preventing complications.
Expecting the stoma to appear pale until healing is complete in (option B) is not necessary to be included in the discussion. A healthy stoma should have a pink or reddish appearance, indicating good blood supply. A pale stoma may suggest poor blood flow, and this should be assessed and reported to the healthcare provider.
Expecting the client's urine to contain clots for the first 24 hours in (option D) is not included in the discussion after urostomy surgery. Urine containing clots may indicate bleeding or other complications, and this should be promptly evaluated by the healthcare team.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Correct answer: A
Option A is correct.In this scenario, the social worker is likely involved in the client's care plan and needs the medical information to provide appropriate support services.Involuntary commitment: In cases of involuntary commitment, there might be a court order allowing for information sharing to ensure the client's well-being..
Option B is incorrect because sharing client information with a client's employer is generally not appropriate without the client's explicit consent. Confidentiality must be maintained, and any concerns about safety due to substance use should be discussed with the client and appropriate healthcare professionals.
Option C is incorrect.Sharing information with a nurse from another unit after a client commits suicide is generally not appropriate unless: there is a specific reason for sharing, such as identifying potential risks to other clients, the minimum amount of information necessary is shared and the sharing complies with HIPAA (Health Insurance Portability and Accountability Act) regulations.
Option D is incorrect because sharing client information with a client's partner after the client reports intimate partner abuse could potentially compromise the client's safety. It is crucial to follow specific protocols and laws related to reporting abuse while ensuring the client's confidentiality and well-being.
Correct Answer is C
Explanation
Phenytoin is known to cause gingival hyperplasia, which is characterized by swollen and enlarged gums. This side effect is more common in long-term use and may require dental care and regular oral hygiene practices.
Phenytoin is known to be associated with an increased risk of birth defects in babies born to women taking the medication during pregnancy. It is important for women of childbearing age to discuss the risks and benefits of phenytoin with their healthcare provider and use effective contraception to avoid pregnancy while taking the medication.
Phenytoin can affect liver function, so regular monitoring of liver enzymes and blood levels of the medication is necessary. The frequency of blood work may vary depending on the individual's specific situation, so it is important to follow the healthcare provider's instructions. It is not advisable to skip a dose of phenytoin without consulting a healthcare provider.
Abruptly stopping or missing doses of antiepileptic medications can lead to breakthrough seizures or other complications. Any changes in the medication regimen should be discussed with the healthcare provider.
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