The nurse is planning care for a patient recovering from bladder neck surgery. What should the nurse include in this patient's plan of care?
Select all that apply.
1. securing urinary catheters in position
2. reporting any onset of bright red urine
3. measuring urine output and reporting changes
4. gently tugging on urinary catheter every shift
5. expecting urine to be pink and gradually clear
Correct Answer: 1, 2, 3, 5
To maintain stability and patency, the catheter should be secured in position. Bright red urine can indicate hemorrhage and should be reported. Urine output should be measured and changes in output reported. Urine color after surgery will be pink and then gradually clear. Pulling on catheters increases the risk for pressure on the surgical incision and should not be done.
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A pericardial friction rub is heard when
A) aortic insufficiency exists. B) ventricular filling is increased. C) the pericardial surfaces are inflamed. D) a pleural friction rub exists.
The nurse notes in the patient's medication orders that the patient will be taking ibutilide (Corvert). Based on this finding, the nurse interprets that the patient has which disorder?
a. Ventricular ectopy b. Atrial fibrillation c. Supraventricular tachycardia d. Bradycardia
The nurse will teach a patient to plan to minimize physical and emotional stress while the patient is undergoing
a. a water deprivation test. b. testing for serum T3 and T4 levels. c. a 24-hour urine test for free cortisol. d. a radioactive iodine (I-131) uptake test.
Upon admission to the postanesthesia care unit (PACU), the client who has no orthopedic or neurological restrictions is positioned with the:
1. Bed flat and the client's arms to the sides 2. Client's neck flexed and body positioned laterally 3. Head of the bed slightly elevated with the client's head to the side 4. Client's arms crossed over the chest and the bed in high-Fowler's position