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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Correct Answer is C

Explanation

A. This would indicate adrenal insufficiency, not Cushing syndrome.
B. Elevated adrenocorticotropic hormone (ACTH) and elevated cortisol would indicate Cushing syndrome caused by pituitary adenoma, not adrenal gland hyperplasia.
C. Low adrenocorticotropic hormone (ACTH) and elevated cortisol is consistent with Cushing syndrome caused by adrenal gland hyperplasia. In this condition, the adrenal glands produce excess cortisol independently of ACTH stimulation.
D. Elevated adrenocorticotropic hormone (ACTH) and low cortisol would indicate adrenal insufficiency, not Cushing syndrome.

A. Furosemide slow IV push B. 0.9% sodium chloride with 5% dextrose C. Ketoconazole and insulin D. Potassium chloride IV infusion

Correct Answer is B

Explanation

A. Furosemide is a loop diuretic used to treat fluid overload by increasing urine output. In an Addisonian crisis, the primary issue is the severe lack of adrenal hormones rather than fluid overload. Administering furosemide is not indicated in this situation, as it does not address the underlying cause of the crisis or correct electrolyte imbalances that are common in Addisonian crisis.
B. This is a common intravenous fluid choice for managing Addisonian crisis. The 0.9% sodium chloride (normal saline) helps to restore blood volume and correct electrolyte imbalances, while the 5% dextrose provides glucose to support energy needs. This combination helps to address hypovolemia (low blood volume) and prevent hypoglycemia (low blood sugar), both of which can occur in an adrenal crisis.

C. Ketoconazole is an antifungal medication that can be used to treat Cushing’s syndrome, not Addisonian crisis. Insulin is used to manage blood glucose levels and would not be the primary treatment for Addisonian crisis. This option does not directly address the adrenal insufficiency or the immediate needs of an Addisonian crisis.
D. Addisonian crisis often presents with hyponatremia (low sodium) and hyperkalemia (high potassium) due to inadequate aldosterone production. Administering potassium chloride could exacerbate hyperkalemia, which is a concern in Addisonian crisis. Therefore, potassium chloride infusion is not appropriate and could worsen the electrolyte imbalance.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a diagnosis of Cushing syndrome. After performing magnetic resonance imaging (MRI), the underlying cause of the condition is found to be hyperplasia of the adrenal glands. Which of the following lab results would the nurse anticipate with this condition?

Correct Answer is C

Explanation

A nurse is admitting a client who is experiencing an Addisonian crisis. Which of the following should the nurse anticipate an order for?

Correct Answer is B

Explanation

A client is admitted to the hospital during an exacerbation of rheumatoid arthritis (RA). Which of the following nursing interventions are appropriate for a client experiencing an RA flare? (Select all that apply.)

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