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 []
Explanation
Potential Condition: Opioid intoxication
Actions to Take:
- Obtain a prescription for naloxone
- Prepare to initiate mechanical ventilation
Parameters to Monitor:
- Pupillary reaction,
- Respiratory rate
Rationale:
- Potential Condition: The client presents with shallow breathing, slurred speech, confusion, pupillary constriction, and bradycardia, which are classic signs of opioid intoxication. The history of back pain also suggests possible opioid use.
- Actions to Take:
- Naloxone is an opioid antagonist that can rapidly reverse respiratory depression caused by opioid overdose.
- Mechanical ventilation may be necessary if respiratory depression is severe and does not improve with naloxone administration.
- Parameters to Monitor:
- Pupillary reaction is important because opioids cause pupillary constriction (miosis). Improvement in pupillary size and reaction indicates the opioid effects are wearing off.
- Respiratory rate should be closely monitored since opioid overdose primarily affects respiratory drive, leading to hypoxia and potential respiratory failure.
Correct Answer is C
Explanation
A. The guardian wants to accompany the child from the ED to the radiology department. This is a typical parental response and does not indicate maltreatment. Parents often want to stay with their child for reassurance.
B. The guardian states the child fell off the swing in the backyard. This is a plausible explanation for an injury in a preschooler, though the consistency of the story with the injury should still be assessed.
C. The child was brought to the ED 2 days after the injury occurred. A delay in seeking medical care for a significant injury is a potential warning sign of child maltreatment and warrants further investigation.
D. The child cries loudly when their arm is moved or manipulated. Pain with movement is expected with a fracture and does not indicate maltreatment.
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