A common nursing diagnosis for a client in the immediate postoperative phase after transurethral resection of the prostate (TURP) is:

Ineffective peripheral tissue perfusion related to deep vein thrombosis

Acute pain related to pain of bladder spasms

Disturbed body image related the disfiguring surgery

Imbalanced nutrition, less than body requirements

Answer and Explanation

The Correct Answer is B

A. While monitoring for complications such as DVT is necessary, it is not the primary concern in the immediate postoperative phase.
B. Acute pain related to bladder spasms is a common postoperative issue for TURP patients due to the urinary catheter and bladder irrigation. Managing pain is a priority for patient comfort and recovery.
C. TURP does not typically lead to body image disturbances as it does not result in visible or disfiguring changes.
D. Imbalanced nutrition is not an immediate postoperative priority following TURP.

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Correct Answer is A

Explanation

A. Respiratory acidosis occurs due to hypoventilation, which causes an accumulation of carbon dioxide in the blood, leading to increased acidity. Shallow respirations at a rate of 8 breaths per minute indicate hypoventilation, putting the client at risk for respiratory acidosis.
B. Metabolic acidosis is typically caused by metabolic issues such as kidney failure or diabetic ketoacidosis, not by respiratory changes.
C. Respiratory alkalosis results from hyperventilation, which leads to a decrease in carbon dioxide levels, causing alkalinity in the blood.
D. Metabolic alkalosis is caused by factors such as prolonged vomiting or diuretic use, not by hypoventilation.

A. Weight B. Heart rate C. Urine output D. BP

Correct Answer is B

Explanation

A. Weight may fluctuate but is not a direct indication of immediate fluid resuscitation adequacy.
B. A decrease in heart rate is a sign of improved perfusion and stabilization, suggesting that fluid replacement is effective in compensating for blood loss.
C. Adequate fluid replacement is indicated by an increase, not a decrease, in urine output.
D. Blood pressure should stabilize or increase with fluid replacement, rather than decrease.

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A common nursing diagnosis for a client in the immediate postoperative phase after transurethral resection of the prostate (TURP) is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative and whose respirations are shallow and 8/min. Which of the following acid-based imbalances should the nurse identify the client as being at risk for developing initially?

Correct Answer is A

Explanation

A nurse is monitoring a client who is admitted with severe hemorrhage from traumatic injury who is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?

Correct Answer is B

Explanation

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