Question

Two days after the creation of an ileal conduit, the nurse notes that the client's urine appears cloudy but is not malodorous. The nurse should: A. Document the finding B. Obtain an order for an antibiotic C. Irrigate the stoma with saline D. Limit the protein intake

Short answer

Answer: A. Document the finding

Step-by-step solution

Define and understand an ileal conduit

An ileal conduit is a surgical procedure that reroutes the urine flow from the kidneys to the surface of the abdomen through a stoma. It is usually performed after the bladder has been removed or has ceased to function.

Analyze the given information

From the given information, we know that: 1. It's two days after the creation of an ileal conduit. 2. The client's urine appears cloudy but not malodorous (smelly).

Understand the possible reasons for cloudy urine

There are several reasons why urine might look cloudy: 1. Dehydration: Concentrated urine can appear cloudy. 2. Infection: Bacteria or white blood cells in the urine might cause cloudiness. 3. Mucus secretion: The ileal conduit may secrete mucus, giving a cloudy appearance to the urine.

Evaluate the options

Now let's evaluate each option: A. Document the finding: This is a reasonable step since the nurse is simply documenting the observation. B. Obtain an order for an antibiotic: This implies that the nurse suspects an infection. However, there is no evidence of infection in this case (urine isn't malodorous). C. Irrigate the stoma with saline: This would be appropriate if there is a blockage. Still, nothing indicates a blockage in the urine flow. D. Limit the protein intake: This would be an appropriate option if the patient is on high protein intake, which could cause cloudy urine. However, there is no information about the client's protein intake.

Choose the best answer

Based on the analysis of the information provided and the possible reasons for the cloudy urine, the most appropriate action for the nurse to take is: A. Document the finding The cloudy appearance of the urine could be a temporary situation or the result of mucus secretion from the ileal conduit, which is not harmful. However, the nurse should continue monitoring the client's condition, and if additional symptoms appear or persist, further steps should be taken accordingly.