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 ["A","E"]

Explanation

A. Proper hand hygiene is critical to prevent introducing infections into the eye, especially after eye surgery. The client should always wash their hands before touching their eyes or administering any eye drops to maintain sterility and reduce the risk of infection.
B. After extracapsular cataract extraction, the cataract itself does not grow back on the implanted lens. However, a condition called posterior capsule opacification (PCO) can occur, where the membrane behind the lens becomes cloudy. This can be treated with a simple outpatient procedure called YAG laser capsulotomy.
C. Bending at the waist can increase intraocular pressure and put strain on the eye, which can hinder healing or increase the risk of complications. The client should be advised to avoid bending over and instead use alternative methods, such as bending their knees or getting assistance to reach items on the ground.
D. In modern cataract surgery, many procedures are performed without sutures or with self-sealing techniques that do not require suture removal. The specific follow-up care, including whether sutures need to be removed, should be confirmed with the surgeon.
E. Wearing an eye shield at night helps protect the eye from accidental rubbing or injury while sleeping, which is crucial for proper healing. The client should follow the physician's instructions regarding the duration of shield use, but wearing it until cleared by the physician is generally recommended to ensure the eye remains protected during the initial healing period.

A. Hemoglobin B. Platelets C. Blood urea nitrogen (BUN) D. B-type natriuretic peptide (BNP)

Correct Answer is D

Explanation

A. Hemoglobin levels measure the oxygen-carrying capacity of the blood. A reduced ejection fraction (30%) is more closely related to heart failure or significant cardiac dysfunction, which is not directly indicated by changes in hemoglobin levels.
B. Platelet levels are primarily involved in blood clotting and are less directly related to ejection fraction. Elevated or decreased platelet counts are not typically used as indicators of heart failure severity or reduced ejection fraction.
C. In cases of severe heart failure with a reduced ejection fraction, you may see elevated BUN levels due to these effects. However, it is not directly related to heart failure.
D. BNP is a hormone released by the heart in response to increased pressure and volume overload, typically seen in heart failure. Elevated BNP levels are associated with worsening heart failure and can be elevated in patients with a reduced ejection fraction. In heart failure, especially with an ejection fraction as low as 30%, BNP levels are often significantly elevated.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge education to a client who has undergone extracapsular cataract extraction surgery. What should the nurse include in the discharge teaching? (Select all that apply.)

Correct Answer is ["A","E"]

Explanation

The nurse is reviewing the results of the client's echocardiogram and observes that the ejection fraction is 30%. Which lab result would the nurse expect to be elevated for a client with this ejection fraction?

Correct Answer is D

Explanation

A client is admitted to the hospital with a diagnosis of Amyotrophic Lateral Sclerosis (ALS). Which finding is consistent with known risk factors for this disease?

A client has had recurrent kidney stones. Upon lab analysis of the client's urine, it is found that excessive oxalate intake is the underlying cause. Which of the following high-oxalate foods should the nurse instruct the client to avoid?

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

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