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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. A GCS score of 3 for eye opening indicates that the client does not open their eyes spontaneously, while a score of 5 for best verbal response suggests that they can respond verbally, likely indicating that they can open their eyes when spoken to or when commanded. This conclusion aligns with the score of 5 for verbal response, which indicates a higher level of responsiveness.

B. This option is incorrect because a score of 5 for best verbal response indicates that the client can produce vocal sounds, meaning they are capable of making verbal responses.

C. While the eye opening score of 3 suggests significant impairment, the overall GCS score of 13 (3 + 5 + 5) does not support the conclusion that the client is completely unconscious. The presence of verbal and motor responses indicates some level of consciousness.

D. This conclusion is incorrect because a score of 5 for best motor response suggests that the client can follow commands and respond to stimuli, which is inconsistent with being unable to follow commands.

A. Difficulty reading B. Aphasia C. Right hemiparesis D. Inability to recognize his family members

Correct Answer is D

Explanation

A. Difficulty reading (alexia) is typically associated with left hemisphere strokes.

B. Aphasia (language impairment) is more commonly associated with left hemisphere damage.

C. Right hemiparesis would result from a left hemisphere stroke.

D. Right hemisphere strokes often result in cognitive and perceptual deficits, such as visual-spatial issues and prosopagnosia, which is the inability to recognize familiar faces.

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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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