A nurse is assisting with the care of a client immediately following a lumbar puncture. Which of the following actions should the nurse take? (Select all that apply.)

Choice A rationale

Contacting the surgeon if the client reports a continual need to void is not necessary unless it is accompanied by other symptoms such as pain or discomfort. The sensation of needing to void can be common after a TURP due to the presence of the catheter and bladder irrigation. This sensation usually resolves as the bladder heals and adjusts to the catheter.
Choice B rationale
Using sterile technique when preparing the irrigation solution is crucial to prevent infection. Sterile technique ensures that no pathogens are introduced into the bladder, which could lead to complications such as urinary tract infections or sepsis. Maintaining a sterile environment is a fundamental aspect of postoperative care, especially when dealing with invasive procedures like TURP1.
Choice C rationale
Adding the amount of bladder irrigation to the total output is incorrect. The correct practice is to subtract the amount of irrigation solution used from the total output to determine the actual urine output. This helps in accurately monitoring the client’s fluid balance and kidney function. Incorrectly adding the irrigation amount could lead to misinterpretation of the client’s urinary output and fluid status.
Choice D rationale
Notifying the surgeon if the urine is bright red or has large clots is essential. Bright red urine or large clots can indicate active bleeding, which is a potential complication after TURP. Early detection and intervention are crucial to prevent significant blood loss and other complications. The nurse should monitor the urine color and consistency closely and report any abnormalities immediately.
Choice E rationale

Ensuring the drainage tubing is patent and without obstruction is vital for the effectiveness of continuous bladder irrigation. Obstructions in the tubing can lead to bladder distention, discomfort, and potential damage to the bladder and urethra. Regularly checking the tubing for kinks or blockages and ensuring a free flow of irrigation solution helps maintain proper bladder function and prevent complications.

Choice A rationale
High fever in the early morning is not a typical finding in pulmonary tuberculosis. TB patients may experience low-grade fevers, but high fevers are less common and usually occur in the evening or at night.
Choice B rationale
Fatigue is a common symptom of pulmonary tuberculosis. TB is a chronic infectious disease that can cause prolonged periods of fatigue and weakness due to the body’s ongoing immune response to the infection.
Choice C rationale

Increased appetite is not a typical finding in pulmonary tuberculosis. TB patients often experience a loss of appetite and unintentional weight loss due to the systemic effects of the infection.
Choice D rationale
Night sweats are a classic symptom of pulmonary tuberculosis. TB patients often experience drenching night sweats as a result of the body’s immune response to the infection. This symptom, along with chronic cough and weight loss, is a key indicator of TB.