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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 ["C","D","E"]

Explanation

A. Ecchymosis, or bruising, may be present but does not directly evaluate neurovascular status.

B. Skin integrity is important for general wound assessment but does not specifically indicate neurovascular function.

C. Sensation assessment helps evaluate nerve function, which is critical in identifying potential neurovascular compromise.

D. Color of the affected limb provides information on blood flow, with pale or cyanotic coloring suggesting potential compromise.

E. Temperature can indicate adequate blood flow; a cooler extremity may suggest poor circulation, indicating neurovascular compromise.

A. Auscultate cuff blood pressure. B. Monitor the pulmonary artery pressure. C. Palpate pulse pressure. D. Obtain a central venous pressure.

Correct Answer is B

Explanation

A. Auscultating blood pressure may not be as reliable in burn patients due to fluid shifts and potential damage to peripheral tissues.

B. Monitoring pulmonary artery pressure provides crucial information about the cardiovascular system's status, including fluid balance and cardiac function, which are essential in the care of clients with severe burns.

C. Palpating pulse pressure alone is insufficient for thorough cardiovascular monitoring in critically ill burn patients.

D. Central venous pressure provides information about fluid status but does not offer the comprehensive cardiovascular data needed for extensive burn management.

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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

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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