Nokea
The nurse is caring for a patient recently diagnosed with renal calculi. The nurse should instruct the patient to increase fluid intake to a level where the patient produces at least how much urine each day?
- A. $1,250 \mathrm{~mL}$
- B. $2,000 \mathrm{~mL}$
- C. $2,750 \mathrm{~mL}$
- D. $3,500 \mathrm{~mL}$
Correct Answer: B
Rationale: Unless contraindicated by renal failure or hydronephrosis, patients with renal stones should drink at least eight 8-ounce glasses of water daily or have IV fluids prescribed to keep the urine dilute. A urine output exceeding2 \mathrm{~L}$ a day is advisable.
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A patient with cancer of the bladder has just returned to the unit from the PACU after surgery to create an ileal conduit. The nurse is monitoring the patients urine output hourly and notifies the physician when the hourly output is less than what?
- A. $30 \mathrm{~mL}$
- B. $50 \mathrm{~mL}$
- C. $100 \mathrm{~mL}$
- D. $125 \mathrm{~mL}$
Correct Answer: A
Rationale: A urine output below30 \mathrm{~mL} / \mathrm{hr}$ may indicate dehydration or an obstruction in the ileal conduit, with possible backflow or leakage from the ureteroileal anastomosis.
A patient has been admitted to the postsurgical unit following the creation of an ileal conduit. What should the nurse measure to determine the size of the appliance needed?
- A. The circumference of the stoma
- B. The narrowest part of the stoma
- C. The widest part of the stoma
- D. Half the width of the stoma
Correct Answer: C
Rationale: The correct appliance size is determined by measuring the widest part of the stoma with a ruler. The permanent appliance should be no more than1.6 \mathrm{~mm}$ (1 / 8$ inch) larger than the diameter of the stoma and the same shape as the stoma to prevent contact of the skin with drainage.
The nurse is caring for a patient who has undergone creation of a urinary diversion. Forty-eight hours postoperatively, the nurses assessment reveals that the stoma is a dark purplish color. What is the nurses most appropriate response?
- A. Document the presence of a healthy stoma.
- B. Assess the patient for further signs and symptoms of infection.
- C. Inform the primary care provider that the vascular supply may be compromised.
- D. Liaise with the wound-ostomy-continence (WOC) nurse because the ostomy appliance around the stoma may be too loose.
Correct Answer: C
Rationale: A healthy stoma is pink or red. A change from this normal color to a dark purplish color suggests that the vascular supply may be compromised. A loose ostomy appliance and infections do not cause a dark purplish stoma.
A patient with kidney stones is scheduled for extracorporeal shock wave lithotripsy (ESWL). What should the nurse include in the patients post-procedure care?
- A. Strain the patients urine following the procedure.
- B. Administer a bolus of500 \mathrm{~mL}$ normal saline following the procedure.
- C. Monitor the patient for fluid overload following the procedure.
- D. Insert a urinary catheter for 24 to 48 hours after the procedure.
Correct Answer: A
Rationale: Following ESWL, the nurse should strain the patients urine for gravel or sand. There is no need to administer an IV bolus after the procedure and there is not a heightened risk of fluid overload. Catheter insertion is not normally indicated following ESWL.
A patient with a sacral pressure ulcer has had a urinary catheter inserted. As a result of this new intervention, the nurse should prioritize what nursing diagnosis in the patients plan of care?
- A. Impaired physical mobility related to presence of an indwelling urinary catheter
- B. Risk for infection related to presence of an indwelling urinary catheter
- C. Toileting self-care deficit related to urinary catheterization
- D. Disturbed body image related to urinary catheterization
Correct Answer: B
Rationale: Catheters create a high risk for UTIs. Because of this acute physiologic threat, the patients risk for infection is usually prioritized over functional and psychosocial diagnoses.