A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate. A triple-lumen catheter for continuous bladder irrigation with normal saline is infusing and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?

Irrigating the catheter manually.

Monitoring catheter drainage.

Discontinuing infusing solution.

Decreasing the flow rate.

Answer and Explanation

The Correct Answer is B

A. Irrigating the catheter manually:
Manually irrigating the catheter without an order may disrupt the clotting process and increase the risk of bleeding. It is not a routine nursing intervention post-TURP without specific orders.

B. Monitoring catheter drainage.
It is not within the nurse's scope of practice to manually irrigate the catheter without a healthcare provider's order, especially in the context of post-TURP care. The dark, pink-tinged outflow with blood clots indicates some expected bleeding following the procedure. The nurse should closely monitor the catheter drainage for the amount, color, and presence of clots.

C. Discontinuing infusing solution:
Discontinuing the normal saline irrigation may lead to clot formation and obstruction, potentially worsening the situation. The continuous bladder irrigation is often used to prevent clot formation and maintain catheter patency post-TURP.

D. Decreasing the flow rate:
The flow rate is typically set by the healthcare provider to maintain catheter patency and prevent clot formation. Decreasing the flow rate without specific orders may not be appropriate in this situation.

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Correct Answer is D

Explanation

A. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules.
Hyperaldosteronism is characterized by an excess of aldosterone, a hormone that regulates sodium and water balance. In cirrhosis, however, sodium retention is often related to other mechanisms such as portal hypertension and hypoalbuminemia, rather than hyperaldosteronism.

B. Decreased renin-angiotensin response related to an increase in renal blood flow.
Cirrhosis is more commonly associated with an activated renin-angiotensin-aldosterone system, leading to increased sodium and water retention. The increased renin-angiotensin response is a compensatory mechanism to maintain perfusion in the setting of cirrhosis and does not contribute to decreased renal blood flow.

C. Decreased portacaval pressure with greater collateral circulation.
This statement is not accurate. In cirrhosis, there is typically increased portacaval pressure due to portal hypertension, which can lead to the development of collateral circulation. However, this does not explain the edema and ascites seen in cirrhosis.

D. Hypoalbuminemia that results in a decreased colloidal oncotic pressure.
This is the correct choice. In cirrhosis, liver damage leads to decreased synthesis of albumin. Albumin plays a crucial role in maintaining colloidal oncotic pressure, and when it is decreased (hypoalbuminemia), fluid is more likely to leak out of blood vessels, resulting in edema. The same mechanism contributes to the development of ascites in the abdominal cavity.

A. Increased temperature to lower extremity. B. Right foot pale with sluggish capillary refill. C. Circumferential edema of right foot. D. Complaint of throbbing right leg pain

Correct Answer is B

Explanation

A. Increased temperature to the lower extremity:
While increased temperature could indicate inflammation or infection, it is not as immediately concerning as impaired circulation.

B. Right foot pale with sluggish capillary refill.
This finding suggests a potential impairment in blood flow to the right foot, which could be due to complications such as compartment syndrome or impaired circulation. Compartment syndrome is a serious condition that occurs when there is increased pressure within a muscle compartment, leading to reduced blood flow. Pale color and sluggish capillary refill indicate compromised circulation and require prompt intervention to prevent further damage.

C. Circumferential edema of the right foot:
Edema is a common finding after a fracture and cast application. However, in the context of pale color and sluggish capillary refill, it may indicate increased pressure within the compartment, requiring immediate attention.

D. Complaint of throbbing right leg pain:
Pain is a common complaint after a fracture, and throbbing pain may be expected. However, the priority is to address the potential compromise in circulation indicated by the pale color and sluggish capillary refill.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?

Correct Answer is D

Explanation

After falling down the basement steps, a client is brought to the emergency room. X-rays confirms that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

Correct Answer is B

Explanation

A female college student comes to the school's health clinic complaining of urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?

A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI Which parameters are most important for the nurse to plan to carefully monitor?

A client who has a history of hypothyroidism was initially admitted with lethargy and confusion Which additional finding warrants the most immediate action by the nurse?

While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

While caring for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse?