A nurse is assessing a client who is 2 days postoperative following a transurethral resection of the prostate and has an indwelling urinary catheter in place. Which of the following findings should the nurse expect?
Small clots with tissue in the urine
Dark red urine
Urinary output 25 mL/hr
Pain of 8 on a scale of 0 to 10
The Correct Answer is A
A. Small clots with tissue in the urine. It is expected for a client 2 days post-TURP to have small clots and tissue debris in the urine as part of the healing process. Continuous bladder irrigation (CBI) often helps clear these.
B. Dark red urine. Bright red or dark red urine can indicate active bleeding, which is not expected 2 days post-op and requires immediate intervention.
C. Urinary output 25 mL/hr. This is too low (normal output should be at least 30 mL/hr) and could indicate catheter blockage, dehydration, or renal impairment, which is not expected.
D. Pain of 8 on a scale of 0 to 10. Mild discomfort is expected, but severe pain (8/10) is abnormal and could indicate bladder spasms, catheter blockage, or another complication requiring intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Yogurt and granola is not appropriate because granola is hard and can be difficult to swallow, increasing the risk of aspiration.
B. Wheat toast with butter is not appropriate because toast is dry and can be difficult to chew and swallow, posing a choking hazard.
C. Pancakes with syrup are soft and easy to chew, making them a suitable choice for a mechanically altered diet. The syrup adds moisture, further aiding swallowing.
D. Banana and nut muffin is not appropriate because muffins can be dry and crumbly, and nuts are a choking hazard for clients with dysphagia.
Correct Answer is D
Explanation
A. A client who has heart failure and received furosemide IV 8 hr ago:
Clients with heart failure require ongoing monitoring for fluid balance, electrolyte levels, and signs of worsening symptoms. IV furosemide indicates active treatment, so this client is not stable for discharge.
B. A client who was admitted 24 hr ago with chest pain:
A client with recent chest pain requires further evaluation for acute coronary syndrome (ACS). Even if pain has resolved, monitoring for cardiac events is essential. This client is not stable for discharge.
C. A client who had a seizure 48 hr ago and is on seizure precautions:
Recent seizures require continued monitoring to assess for recurrence, medication adjustments, and safety precautions. This client is not stable for discharge.
D. A client who is scheduled to have a colonoscopy in 12 hr:
A colonoscopy is an elective procedure and does not require hospitalization. This client is stable and can be discharged to free up resources for mass casualty victims.
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