A nurse is assessing a client who is postoperative following a transurethral resection of the prostate and is receiving continuous bladder irrigation. The client reports bladder spasms, and the nurse notes a scant amount of fluid in the urinary drainage bag. Which of the following actions should the nurse take?
Apply a cold compress to the suprapubic area.
Secure the urinary catheter to the upper left quadrant of the client's abdomen.
Use 0.9% sodium chloride to perform an intermittent bladder irrigation.
Encourage the client to urinate every 2 hr.
The Correct Answer is C
A) This is not a standard intervention for bladder spasms post-TURP.
B) Securing the urinary catheter to the abdomen does not address the immediate issue of potential catheter blockage.
C) Performing an intermittent bladder irrigation using sodium chloride is appropriate in this case. This is because bladder spasms and a scant amount of fluid in the urinary drainage bag may indicate a blockage in the catheter. Intermittent bladder irrigation can help to remove any clots or debris that may be causing the blockage.
D) Encouraging the client to urinate is not applicable as the client cannot urinate normally due to the surgery.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) The Morse Fall Risk scale assesses the risk of falls in hospitalized patients but is not the priority for a postoperative client with an ORIF.
B) The Braden scale assesses the risk of pressure ulcers and is not the priority for a postoperative client with an ORIF.
C) Pain assessment is important but may not be the priority compared to assessing neurovascular status, especially immediately postoperatively.
D) The neurovascular assessment, including circulation, sensation, and movement, is crucial for early detection of complications such as compartment syndrome or impaired blood flow.
Correct Answer is B
Explanation
A) Administering the transfusion through a 25-gauge saline lock might not be appropriate as it may cause hemolysis or obstruct the flow of plasma.
B) Administering the plasma immediately after thawing is crucial to ensure the effectiveness of the transfusion and to prevent degradation of the plasma components.
C) Transfusing the plasma over 4 hours is a standard practice, but the priority is administering it promptly after thawing.
D) Holding the transfusion if the client is actively bleeding is inappropriate since the client is losing blood which needs to be replaced. Furthermore, fresh frozen plasma contains clotting factors which are beneficial for a client whose cause of bleeding is clotting factor deficiencies.
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