A nurse is assisting with the care of a client who has had a prostatectomy.

Select the 2 actions the nurse should prepare to take for the client.

Encourage prolonged dangling before ambulation.

Encourage oral fluid intake.

Assist the client with a sitz bath.

Irrigate indwelling catheter with 500 mL of fluid.

Administer an enema.

Answer and Explanation

Correct Answer : B,C

A. Encourage prolonged dangling before ambulation: While dangling at the bedside can help prevent orthostatic hypotension, the client is already ambulating independently without reported dizziness or hypotension. Prolonged dangling is unnecessary and does not address the current issues of urinary discomfort and bowel cramping.

B. Encourage oral fluid intake: Adequate hydration helps maintain urine flow, prevent catheter obstruction, and support bowel function. Encouraging fluids also helps dilute urine, reducing bladder irritation and the risk of infection, which is especially important post-prostatectomy.

C. Assist the client with a sitz bath: A sitz bath can relieve perineal discomfort, reduce pain, and promote relaxation of the pelvic muscles. Given the client’s bladder fullness and postoperative cramping, this noninvasive intervention helps improve comfort and facilitate urination.

D. Irrigate indwelling catheter with 500 mL of fluid: Routine irrigation with such a large volume is not recommended and may cause trauma or introduce infection. Catheter irrigation should only be performed according to provider prescription and typically with small, prescribed amounts.

E. Administer an enema: The client reports only a single hard, painful bowel movement, and routine enema administration is not indicated. Enemas should be reserved for severe constipation or impaction, and inappropriate use can cause irritation or fluid shifts.

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Correct Answer is C

Explanation

A. Frequent urge to urinate: Urinary frequency and urgency are expected findings after TURP due to bladder and urethral irritation from surgery and catheterization. These sensations typically improve as inflammation subsides and do not require immediate provider notification.

B. Occasional small clots in the urine: Small clots can be expected during the early postoperative period following TURP as the prostatic tissue heals. Continuous bladder irrigation often helps flush these clots, and their presence alone does not indicate a complication unless they become large or obstruct urine flow.

C. Dark red urine: Dark red urine indicates active bleeding and is an abnormal finding 1 day post-TURP. This suggests possible hemorrhage or inadequate hemostasis and requires prompt provider notification to prevent complications such as clot retention or hypovolemia.

D. Urine output of 300 mL over 8 hr: This urine output averages approximately 37.5 mL/hr, which is within acceptable limits for an adult postoperative client. Adequate output suggests sufficient renal perfusion and does not require immediate intervention.

A. Coffee B. Yogurt C. Apple juice D. ice cream

Correct Answer is B

Explanation

A. Coffee: Coffee is a stimulant and can increase gastrointestinal motility, which may worsen diarrhea. It does not help restore the balance of gut flora disrupted by antibiotics and is not recommended.

B. Yogurt: Yogurt contains probiotics, which help replenish healthy intestinal bacteria that can be reduced during antibiotic therapy. Consuming yogurt can help restore gut flora balance and reduce the likelihood or severity of antibiotic-associated diarrhea.

C. Apple juice: Apple juice is high in sugar and can have an osmotic effect in the intestines, potentially worsening diarrhea. It does not contribute to restoring normal gut flora and is not recommended to prevent antibiotic-related diarrhea.

D. Ice cream: Ice cream contains lactose, which can be difficult for some clients to digest, especially when gut flora is disrupted by antibiotics. This may exacerbate diarrhea rather than reduce it, making it inappropriate.

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A nurse is assisting with the care of a client who has had a prostatectomy. Select the 2 actions the nurse should prepare to take for the client.

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A nurse is assisting with the care of a client who has had a prostatectomy.

Select the 2 actions the nurse should prepare to take for the client.