The nurse is caring for a postoperative patient whose urinary ...

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The nurse is caring for a postoperative patient whose urinary catheter was removed 8 hours previously. The patient has not been able to void since the catheter was removed and now reports suprapubic pain. What is the priority action of the nurse?
 
  a. Encourage oral fluid intake and administer a diuretic.
  b. Obtain a urine sample to test for culture and sensitivity.
  c. Carefully calculate the patient's daily intake and output.
  d. Obtain an order to straight-catheterize the patient.

Question 2

The nurse is caring for a patient who recently underwent ileal conduit surgery. Which nursing diagnosis is the highest priority for this patient?
 
  a. Ineffective sexuality pattern related to changed body structure
  b. Social isolation related to potential for accidental leakage of urine
  c. Knowledge deficit related to care and maintenance of ostomy appliance
  d. Disturbed body image related to presence of stoma and appliance

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Answer to Question 1

ANS: D
The patient who has not voided for 8 hours after urinary catheter removal and is complaining of suprapubic pain has acute urinary retention. The physician should be notified to obtain an order for straight catheterization to drain the bladder. A urine sample for culture and sensitivity is not ordered. Encouraging fluid intake and administering a diuretic will increase the amount of urine in the bladder and make the patient even more uncomfortable.

Answer to Question 2

ANS: C
The patient with a new ileal conduit needs to learn how to care for the urinary stoma and appliance prior to discharge from the hospital. If the appliance is not used and applied correctly, the patient may experience urinary leakage and significant skin breakdown from exposure to urine. The other diagnoses are less important than the patient's knowledge deficit about ostomy care.

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