A client has undergone a transurethral resection of the prostate (TURP) for benign prostatic hypertrophy (BPH). He is currently being treated with continuous bladder irrigation (CBI) and is complaining of an increase in the severity of bladder spasms. Which intervention should the nurse perform first?

Perform a bladder scan.

Stop the irrigation and note findings in the chart.

Administer an oral analgesic.

Ensure that the catheter is draining properly.

Answer and Explanation

The Correct Answer is D

Choice A Reason
Performing a bladder scan can help determine the volume of urine in the bladder and assess for urinary retention, which could contribute to bladder spasms. However, this is not typically the first intervention. The priority is to ensure that the catheter is patent and draining correctly, as blockages can cause immediate discomfort and increased spasms

Choice B Reason
Stopping the irrigation could be considered if there is a concern that the CBI is contributing to the spasms. However, this would not be the first action taken. It is essential first to assess the catheter's patency and the flow of the irrigation to rule out any obstruction or kinking causing the spasms.

Choice C Reason
Administering an oral analgesic may help alleviate the discomfort caused by bladder spasms, but it does not address the underlying cause. Pain relief is important, but the initial step should be to check for and resolve any mechanical issues with the catheter system that could be causing the spasms.

Choice D Reason
Ensuring that the catheter is draining properly is the first and most crucial intervention. If the catheter is blocked or kinked, it can cause bladder distention and increased spasms. Checking the catheter's patency and the flow of irrigation can quickly resolve the issue and provide relief to the patient. If the catheter is found to be obstructed, resolving the blockage can decrease the severity of the spasms and improve the patient's comfort.

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Correct Answer is B

Explanation

Choice a reason:

A cream to soothe itching may be used if the client is experiencing pruritus, which can sometimes accompany biliary issues due to bile salts in the skin. However, pruritus is not a direct symptom of biliary colic, which is characterized primarily by pain.

Choice b reason:

Pain medication is the appropriate treatment for biliary colic. Biliary colic is caused by the temporary blockage of the bile duct by a gallstone, leading to intense pain in the upper right abdomen or the center of the abdomen. Pain relief is typically achieved with anti-inflammatory drugs or antispasmodics, and in some cases, opioids may be necessary.

Choice c reason:

An antibiotic would be prescribed if there was an infection, such as cholecystitis or cholangitis. Biliary colic itself does not necessarily indicate an infection unless accompanied by other symptoms such as fever or elevated white blood cell count.

Choice d reason:

A laxative is not typically used to treat biliary colic. While laxatives can help relieve constipation, biliary colic is a result of gallstones obstructing the bile duct, not bowel movement issues.

A. Increased blood glucose levels. B. Increased potassium levels. C. Increased white blood cell count. D. Increased ketones in the urine.

Correct Answer is A

Explanation

Choice A reason:
Prednisone is a corticosteroid that can cause hyperglycemia, especially in clients with diabetes. The nurse should monitor blood glucose levels because prednisone can increase insulin resistance and hepatic glucose production, leading to elevated blood glucose levels. Normal fasting blood glucose levels range from 70 to 99 mg/dL, and for individuals with diabetes, maintaining blood glucose levels within the target range set by their healthcare provider is crucial to prevent complications.

Choice B reason:
While corticosteroids can affect electrolyte balance, they typically cause a decrease in potassium levels, not an increase. Therefore, monitoring for hypokalemia, rather than hyperkalemia, would be more appropriate when a patient is on prednisone. The normal range for serum potassium is 3.5 to 5.0 mEq/L.

Choice C reason:
Corticosteroids like prednisone can cause leukocytosis, an increase in white blood cell count, as part of their immunosuppressive action. However, this is generally not a harmful side effect unless accompanied by infection or other complications. The normal range for white blood cell count is approximately 4,500 to 11,000 cells per microliter.

Choice D reason:
Increased ketones in the urine, or ketonuria, is not a typical side effect of prednisone. Ketonuria is more commonly associated with uncontrolled diabetes, particularly Type 1 diabetes, when there is an insulin deficiency and the body resorts to fat breakdown, leading to ketone production.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The physician has seen the client and informed the nurse that the client is suffering from an episode of biliary colic. The nurse should check the medication record for a prescription to give:

Correct Answer is B

Explanation

A client with Type 2 diabetes, controlled with diet and metformin, also has chronic obstructive pulmonary disease (COPD). During an exacerbation of COPD, the client is prescribed prednisone to control inflammation. For which side effect should the nurse monitor the client?

Correct Answer is A

Explanation

The nurse is reviewing the laboratory findings for a 34-year-old woman who is scheduled for a Schilling's test for B12 deficiency anemia. Which result should the nurse report immediately to the primary care provider?

A client diagnosed with depression expresses a preference for alternative therapy over prescription medication. Which alternative therapy has been shown to be effective in treating this client's condition?

A client is receiving isoniazid after being diagnosed with tuberculosis. Which information should the nurse include in the client's teaching plan?

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For which of the following behaviors would limit setting be most essential? The client:

A client diagnosed with emphysema states that it is uncomfortable to sit in a semi-Fowler's position. In order to best decrease the work of breathing, the nurse should assist the client to:

The nurse is providing discharge teaching to a client with angina pectoris who is prescribed metoprolol 50 mg PO daily. Which information should the nurse include in the teaching?

A nurse formulates the problem of ineffective airway clearance for a client who has pneumonia. Which assessment data best supports this problem?