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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Cataract surgery is typically performed under local anesthesia with sedation, not general anesthesia.
B. Seeing dark spots is not a common or expected outcome. Some clients may experience temporary blurriness, but not dark spots.
C. Bruising of the eyelids is not a typical side effect of cataract removal. There may be mild swelling or redness, but significant bruising is unusual.
D. Cataract removal involves removing the cloudy lens and replacing it with an artificial intraocular lens (IOL) to restore clear vision. This statement shows the client understands the procedure.

A. The client has been in the restraints for 4 hr. B. The client can explain the reasons for their behavior. C. The client is able to calmly follow commands." D. The client reports that the restraints are too tight.

Correct Answer is C

Explanation

A. The client has been in the restraints for 4 hr. This is incorrect because the duration of restraint use is determined by the client's behavior and safety, not a set time frame. Restraints should be discontinued as soon as they are no longer necessary.
B. The client can explain the reasons for their behavior. This is incorrect because insight into behavior does not necessarily indicate that the client is no longer a danger to themselves or others.
C. The client is able to calmly follow commands. This is correct because the primary indication for removing restraints is when the client demonstrates self-control and the ability to follow directions, reducing the risk of harm.
D. The client reports that the restraints are too tight. This is incorrect because a complaint of tight restraints indicates a need for reassessment and possible adjustment, but not necessarily discontinuation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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