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A nurse is preforming postoperative care for a client who is scheduled for an ileal conduit procedure. The nurse should include which of the following in the client's plan of care? (Select All that Apply.)

Maintain the client on fluid restriction

Educate the client that hematuria is expected following the procedure

Notify the provider immediately if mucus is present in the urine

Apply skin barrier to the stoma site

Monitor hourly urine output

Answer and Explanation

Correct Answer : B,D,E

A. Fluid restriction is generally not indicated; maintaining hydration is important to ensure adequate urine output.

B. Hematuria is expected postoperatively due to surgical manipulation and should be explained to the client.

C. Mucus in the urine is common with an ileal conduit since the conduit is created using a portion of the intestine, which naturally produces mucus.

D. Applying a skin barrier protects the skin around the stoma site from irritation and breakdown.

E. Monitoring hourly urine output helps assess kidney function and the patency of the conduit.

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Correct Answer is A

Explanation

A. Wrapping the residual limb in a figure-eight configuration provides compression and support, shaping the limb for prosthesis fitting, and promoting proper circulation.

B. Wrapping in a proximal-to-distal direction can restrict blood flow and does not provide the appropriate support needed for prosthetic shaping.

C. The bandage should be rewrapped more frequently than once a day to maintain compression and limb shape.

D. Securing the bandage at the lowest joint is inadequate as it may allow loosening and improper shaping of the residual limb.

A. Ambulating soon after surgery B. Massaging her legs C. Elevating her feet D. Flexing her ankles

Correct Answer is B

Explanation

A. Ambulating soon after surgery is encouraged to promote circulation and decrease the risk of VTE.

B. Massaging the legs is unsafe, as it can dislodge any existing clot, potentially leading to a pulmonary embolism.

C. Elevating the feet helps improve venous return and is a safe practice to reduce VTE risk.

D. Flexing the ankles is part of exercises that help promote blood flow and reduce clot formation risk.

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A nurse is preforming postoperative care for a client who is scheduled for an ileal conduit procedure. The nurse should include which of the following in the client's plan of care? (Select All that Apply.)

Nursing Test Bank

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