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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["50"]
Explanation
Flow rate in gtt/min = (Volume in mL * Drop factor) / Time in minutes.
The prescribed volume is 150 mL/hr. Since there are 60 minutes in an hour, the time for one hour would be 60 minutes. The drop factor is 20 gtt/mL.
(150 mL/hr * 20 gtt/mL) / 60 min/hr = 3000 gtt/hr / 60 min/hr = 50 gtt/min.
Therefore, the nurse should set the manual IV infusion to deliver 50 gtt/min.
Correct Answer is C
Explanation
A. Casts in the urine are typically associated with kidney problems, such as glomerulonephritis or kidney infections, rather than biliary obstruction. Casts are formed from proteins or cells in the renal tubules and are not related to bile duct obstruction or cholelithiasis.
B. Dark, tarry stools are indicative of upper gastrointestinal bleeding and the presence of digested blood in the stool. This condition, known as melena, is not typically associated with obstruction of the common bile duct due to cholelithiasis.
C. Jaundice is a common and significant finding in cases of obstruction of the common bile duct due to cholelithiasis. When the bile duct is obstructed, bilirubin, which is a component of bile, accumulates in the bloodstream because it cannot be properly excreted into the intestine.
D. Pain from cholelithiasis (gallstones) typically occurs in the right upper quadrant, not the left. The right upper quadrant pain is often associated with gallbladder inflammation or bile duct obstruction.
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