A nurse removes a client's Foley catheter and documents that the client urinates 4 hours later. Which of the following elements of postoperative care is the nurse performing?
Providing surgical site or wound care
Managing postoperative pain
Assisting with early ambulation
Monitoring urinary function
The Correct Answer is D
Choice A reason: The nurse is not providing surgical site or wound care by documenting urination.
Choice B reason: Managing postoperative pain is not directly related to monitoring the client's ability to urinate.
Choice C reason: Assisting with early ambulation does not pertain to the urinary function directly.
Choice D reason: Monitoring urinary function is part of postoperative care, especially after removal of a Foley catheter, to ensure the client is able to void normally.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Flank pain is a common symptom of PKD due to the enlargement of cysts within the kidneys.
Choice B reason: Confusion is not a direct symptom of PKD but could be related to complications such as severe hypertension or toxins in the blood due to decreased kidney function.
Choice C reason: Hypotension is not typically associated with PKD; in fact, hypertension is a more common finding due to the disease's impact on kidney function.
Choice D reason: Urinary retention is not a typical finding in PKD. Instead, symptoms like hematuria (blood in the urine) and increased urinary frequency may occur.
Correct Answer is D
Explanation
The correct answer is D. Urine output 75 mL in 1 hr.
Adequate urine output (at least 30 mL/hr) indicates effective hydration, showing that the kidneys are functioning properly and fluid balance is improving. A urine output of 75 mL in 1 hour suggests sufficient fluid replacement.
Here’s why the other options are incorrect:
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A. Urine specific gravity 1.005 to 1.030 – This range covers both normal and abnormal values. In dehydration, urine specific gravity is usually high (>1.030) due to concentrated urine. Effective treatment should lead to lower urine specific gravity, but the full range does not confirm improvement.
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B. Decreased pulse pressure – Pulse pressure is the difference between systolic and diastolic blood pressure. Dehydration typically causes a narrowed pulse pressure, so improvement should lead to a normal or increased pulse pressure rather than a decrease.
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C. Lightheadedness – Dizziness and lightheadedness are signs of dehydration-related hypotension. Effective hydration should resolve these symptoms, not maintain them.
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