A nurse is discussing the plan of care of a client who Is 4 hr postoperative and has a urostomy with an assistive personnel. Which of the following statements should the nurse include in the discussion?
"Expect the client's urine to contain clots for the first 24 hours."
"We need to check the client's urine output every hour."
"Expect the stoma to appear pale until healing is complete."
"We will keep the client's fluid intake restricted until he is free of pain."
The Correct Answer is B
Postoperative care of a client with a urostomy focuses on monitoring urinary elimination, ensuring stoma viability, and maintaining adequate hydration and renal function. A urostomy diverts urine from the ureters to a stoma on the abdominal wall, making urine output a key indicator of kidney perfusion and surgical patency. In the immediate postoperative period, frequent assessment is essential to detect early complications such as obstruction, bleeding, or impaired renal drainage. Nursing care emphasizes close monitoring and accurate documentation of urine output.
Rationale:
A. Urine containing clots is not expected after urostomy formation and may indicate bleeding or complications at the surgical site. While minor blood-tinged urine may occur initially, persistent clots are abnormal and require prompt evaluation. This statement reflects incorrect expectations of postoperative findings.
B. Monitoring urine output every hour is essential in the immediate postoperative period because it provides critical information about renal perfusion and stoma function. In a client with a newly created Urostomy, hourly output assessment helps detect early complications such as obstruction, dehydration, or impaired kidney function. This is a key priority intervention in acute postoperative care.
C. A healthy stoma should appear pink to red and moist, indicating adequate blood supply. A pale or dusky stoma suggests decreased perfusion and possible ischemia, which is an emergency. Therefore, expecting a pale stoma is incorrect and indicates a misunderstanding of normal findings.
D. Fluid intake should not be restricted after urostomy surgery unless specifically prescribed. Adequate hydration is essential to promote urine flow, prevent mucus accumulation, and reduce the risk of urinary tract infection or blockage. Restricting fluids could worsen postoperative complications and impair renal function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A low-sodium diet is commonly prescribed for clients with conditions such as hypertension, heart failure, and certain renal disorders to reduce fluid retention and decrease cardiovascular workload. Sodium restriction helps prevent edema and supports better blood pressure control. Teaching focuses on avoiding processed, preserved, and canned foods that contain high sodium levels while encouraging fresh, minimally processed food options. Nurses guide clients in identifying safer dietary choices that align with sodium restrictions.
Rationale:
A. Green olives are high in sodium due to the brining and curing process used for preservation. Even small portions can significantly increase daily sodium intake. Therefore, olives are not recommended in a low-sodium diet.
B. A bologna sandwich is high in sodium because processed meats like bologna contain large amounts of salt and preservatives. These foods contribute significantly to fluid retention and increased blood pressure. They are typically restricted in sodium-controlled diets.
C. Canned tuna often contains added sodium for preservation unless specifically labeled “no salt added” or “low sodium.” Regular canned varieties can contribute to excessive sodium intake. Therefore, it is not the best choice for a low-sodium diet.
D. Scrambled eggs are correct because eggs in their natural form are low in sodium and minimally processed. They provide high-quality protein without significantly increasing sodium intake. In dietary management of conditions such as Low-sodium diet, fresh foods like eggs are appropriate recommendations.
Correct Answer is D
Explanation
Intermittent enteral feeding through a percutaneous endoscopic gastrostomy (PEG) tube is used to provide nutrition directly into the stomach for clients who cannot meet nutritional needs orally. Safe administration requires preventing tube occlusion, reducing aspiration risk, and ensuring proper placement and patency of the feeding tube. Nursing care includes appropriate positioning, flushing protocols, and monitoring for gastric residuals. Proper technique supports tolerance of feeding and reduces complications such as aspiration pneumonia and tube blockage.
Rationale:
A. Positioning the client supine for 1 hour following feeding is incorrect because lying flat increases the risk of aspiration. Gastric contents may reflux into the esophagus and airways, especially in clients receiving enteral nutrition. The head of the bed should be elevated during and after feeding to promote gastric emptying and reduce aspiration risk.
B. Withholding feeding if 50 mL of residual is present is not a universal guideline because acceptable residual volumes vary by facility policy. In many cases, 50 mL is considered within acceptable limits and does not require holding the feeding unless accompanied by other signs of intolerance. Clinical judgment and institutional protocols should guide management.
C. Elevating the head of the bed 20 degrees is insufficient to prevent aspiration. The recommended position for enteral feeding is typically 30–45 degrees elevation to reduce the risk of reflux and aspiration. Lower elevations do not provide adequate protection during feeding.
D. Administering 30 mL of water prior to the feeding is correct because flushing the PEG tube ensures patency and helps prevent clogging. It also verifies that the tube is clear before delivering nutrition. In care of clients with devices such as Percutaneous endoscopic gastrostomy (PEG) tube, routine water flushes before and after feedings are essential for maintaining tube function and safe nutrition delivery.
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