Ch 55 NCLEX Flashcards | Quizlet

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2/11/24, 8 : 17 PM Ch 55 NCLEX Flashcards | Quizlet Page 3 of 25 https://quizlet.com/44241148/ch-55-nclex-flash-cards/ manage stoma care. The nurse caring for a patient with a urinary diversion notices mucus around the stents and in the patient's urine. The appropriate nursing intervention is to do which of the following? a) Document presence of mucus in the urine. b) Remove the urinary stents. c) Contact the physician. d) Document the separation of the mucocutaneous junction. a) Document presence of mucus in the urine. Explanation: The nurse should document the presence of mucus in the urine as this is a normal finding in urinary diversions.
2/11/24, 8 : 17 PM Ch 55 NCLEX Flashcards | Quizlet Page 4 of 25 https://quizlet.com/44241148/ch-55-nclex-flash-cards/ If an indwelling catheter is necessary, which of the following nursing interventions should be implemented to prevent infection? a) Using clean technique during insertion b) Placing the catheter bag on the patient's abdomen when moving the patient c) Performing meticulous perineal care daily with soap and water d) Using sterile technique to c) Performing meticulous perineal care daily with soap and water Explanation: Cleanliness of the area will reduce potential for infection. Strict aseptic technique must be used during insertion of a urinary bladder catheter. The nurse must maintain a closed system and use the catheter's port to obtain specimens. The catheter bag must never be placed on the patient's abdomen unless it is clamped because it may cause backflow of urine from the tubing into the bladder.
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