A nurse is discussing the plan of care of a client who is 4 hr postoperative and has a urostomy with an assistive personnel. Which of the following statements should the nurse include in the discussion?
Explanation & Rationale
The correct answer is A. "We need to check the client's urine output every hour." Choice A rationale: Monitoring urine output every hour is crucial for assessing kidney function and ensuring the urostomy is functioning properly, especially in the immediate postoperative period. Choice B rationale: A pale stoma is not an expected finding. A healthy stoma should be pink to red. A pale stoma could indicate inadequate blood supply and needs immediate evaluation. Choice C rationale: While some blood or small clots in the urine might be expected shortly after surgery, this is not a standard instruction to give. Any significant or persistent bleeding should be reported and assessed promptly. Choice D rationale: Restricting fluid intake is generally not recommended after surgery unless specifically ordered. Adequate hydration is important for recovery and maintaining urinary output.