A client is admitted for an elective transurethral resection of the prostate (TURP). The client is receiving continuous bladder irrigation (CBI) after the procedure. In the post-anesthesia care unit (PACU), the nurse takes the client's vital signs and checks the urinary drainage bag frequently. Which assessment finding should the nurse prioritize reporting to the provider as an indication of a possible complication?

Blood pressure of 132/60 mmHg and heart rate of 90 beats per minute

Output to the Foley catheter has stopped

The patient reports a pain level of 5/10

Pink-colored urine in the Foley collection bag

Answer and Explanation

The Correct Answer is B

A. This blood pressure and heart rate are within normal ranges for most patients. For example, a blood pressure of 132/60 mmHg is slightly elevated on the systolic side but not critically so, and a heart rate of 90 beats per minute is within the normal range (60-100 beats per minute).
B. Continuous bladder irrigation is used to prevent clots and debris from obstructing the urinary tract after a TURP. If the output from the Foley catheter has stopped, it may indicate a blockage or clot in the catheter or bladder, which can lead to bladder distension, discomfort, and potential kidney damage.
Immediate reporting to the provider is crucial because this could indicate a severe complication.
C. Pain levels are subjective, and a pain level of 5/10 indicates moderate discomfort. While pain management is important, a pain level of 5/10 is not unusual after TURP, and it can often be managed with appropriate pain relief measures.
D. Pink-colored urine is not uncommon immediately following a TURP as a result of bleeding or irritation from the procedure. This finding can be expected and may not indicate an immediate complication.
However, if the urine color changes to bright red or if there is a significant increase in blood, it could be more concerning.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A. While vitamin A can interact with some medications, it does not have a significant effect on verteporfin.
B. Verteporfin does not typically affect blood sugar levels.
C. Verteporfin is usually administered intravenously, so it is not taken orally.
D. Verteporfin is a photosensitizing agent used in photodynamic therapy for age-related macular degeneration. After treatment with verteporfin, the client should avoid sunlight and other intense light for several days to prevent a severe sunburn-like reaction. This is because verteporfin makes the skin and eyes more sensitive to light.

A. A client who is being treated for otitis media B. A client who has experienced an injury to the eardrum C. A client who works in a loud environment D. A client whose ear canal is impacted with wax

Correct Answer is C

Explanation

A. Otitis media is an infection or inflammation of the middle ear. This condition primarily affects the middle ear structures and can cause conductive hearing loss, which is due to problems with sound transmission through the outer or middle ear.
B. An injury to the eardrum, such as a perforation, can lead to conductive hearing loss. This occurs because the eardrum (tympanic membrane) is crucial for transmitting sound waves from the outer ear to the middle ear. While an eardrum injury affects sound transmission, it does not directly damage the inner ear or auditory nerve, so it does not typically cause sensorineural hearing loss.
C. Exposure to loud noise is a common cause of sensorineural hearing loss. Prolonged or intense noise exposure can damage the sensory hair cells in the cochlea or the auditory nerve pathways, leading to permanent hearing loss. This type of hearing loss is due to damage in the inner ear or auditory nerve rather than the outer or middle ear structures.
D. Impacted earwax can cause conductive hearing loss by blocking sound transmission through the ear canal. This type of hearing loss is due to a blockage and is usually reversible once the wax is removed. It does not cause sensorineural hearing loss, which involves damage to the inner ear or auditory nerve.

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Naxlex Comprehensive Predictor Exams

A client with age-related macular degeneration (AMD) is undergoing photodynamic therapy with the medication Verteporfin. What should the nurse include in the discharge teaching for this client?

Correct Answer is D

Explanation

Which of the following clients is at risk for sensorineural hearing loss?

Correct Answer is C

Explanation

A client experiencing exophthalmos is seen in a primary care provider's clinic. The nurse understands that the most likely endocrine disorder which would cause this symptom is which of the following?

A nurse is caring for a client who has undergone a bilateral adrenalectomy. The nurse monitors for which of the following signs of Addisonian crisis?

A nurse is assessing a client who is 12 hours postoperative following a thyroidectomy. Which of the following findings is indicative of thyrotoxic crisis?

A staff nurse is teaching a client who has secondary hypothyroidism about the disease process. The client asks the nurse what causes secondary hypothyroidism. Which of the following responses should the nurse make?

A client has been on daily, high-dose prednisone therapy to treat an exacerbation of rheumatoid arthritis. His prescription runs out before his next paycheck. He decides to skip his prednisone for a few days. What is likely to happen to this patient when he abruptly stops taking prednisone?

A client has been diagnosed with age-related macular degeneration (AMD). Which change in vision would the nurse expect a client with AMD to report?

A nurse is caring for a client who has inflammation of the glomeruli which was discovered by a routine urinalysis. The nurse understands that which of the following autoimmune disorders can cause chronic glomerulonephritis?

The patient is admitted with upper GI bleeding following an episode of forceful vomiting due to excessive alcohol intake. The nurse suspects a Mallory-Weiss tear. Which of the following is true of a Mallory-Weiss tear?