A nurse is caring for a client who had a transurethral resection of the prostate and now is receiving continuous bladder irrigation. Which of the following actions should the nurse take? (Select all that apply.)
Document urine color
Monitor the client for reports of bladder spasms.
Check the drainage tubing for obstructions
Maintain the client in a left side-lying position
Use clean technique for intermitent irrigation
Correct Answer : A,B,C
The correct answers are a. Document urine color, b. Monitor the client for reports of bladder spasms, and
c. Check the drainage tubing for obstructions.
a. Documenting urine color is important to monitor for any changes that may indicate complications or issues with the bladder irrigation. It helps identify any bleeding or clot formation.
b. Monitoring the client for reports of bladder spasms is crucial as bladder spasms can indicate irritation or obstruction in the urinary system. Prompt intervention can be provided to alleviate discomfort and prevent complications.
c. Checking the drainage tubing for obstructions is essential to ensure proper flow of the bladder irrigation solution. Obstructions in the tubing can lead to inadequate irrigation, which can affect the effectiveness of the procedure and potentially lead to complications.
d. Maintaining the client in a left side-lying position is not specifically indicated for continuous bladder irrigation after a transurethral resection of the prostate. The client's position should be based on their comfort and overall condition, and there is no specific requirement for a left side-lying position in this context.
e. Using clean technique for intermitent irrigation is not appropriate for continuous bladder irrigation. Continuous bladder irrigation requires aseptic technique to reduce the risk of infection and contamination.
By performing these actions, the nurse ensures proper monitoring, documentation, and maintenance of the bladder irrigation system, promoting the client's safety and well-being.

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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Compartment syndrome occurs when there is increased pressure within a closed muscle compartment, leading to reduced blood flow to the muscles and nerves in that compartment. In this case, the open fracture and subsequent reduction and stabilization procedure can cause swelling and increased pressure within the affected compartment. This can impede blood flow and potentially lead to tissue damage. Common symptoms include severe pain, swelling, numbness, and decreased or absent pulses. Immediate medical attention is necessary if compartment syndrome is suspected.
Deep Vein Thrombosis (DVT) refers to the formation of blood clots within the deep veins, typically in the lower extremities. In the case of a client with an open fracture and immobilization with a splint, the risk of DVT increases due to factors such as reduced mobility, injury to blood vessels, and blood stasis. DVT can lead to serious complications if a clot dislodges and travels to the lungs, causing a pulmonary embolism. Symptoms of DVT may include pain, swelling, warmth, and redness in the affected limb.
While osteomyelitis and fat embolism syndrome can occur as complications of long bone fractures, they are not explicitly mentioned in the given scenario. Osteomyelitis refers to an infection in the bone, which can develop if bacteria enter an open fracture. Fat embolism syndrome can occur when fat globules from the bone marrow enter the bloodstream, usually following a long bone fracture.

Correct Answer is B
Explanation
b. "You feel upset by the responses of others."
The appropriate response by the nurse is to acknowledge and validate the client's feelings. Option b, "You feel upset by the responses of others," demonstrates empathy and reflects back the client's feelings, indicating that the nurse understands and acknowledges the client's distress.
Explanation for the other options:
a. "I think you should just ignore the others." This response dismisses the client's concerns and does not address the underlying issue of the client feeling hurt by the interactions with others. It is important for the nurse to address the client's feelings and provide support.
c. "Let's keep the focus of our discussion on your needs." While it is important to address the client's needs, it is also necessary to address the client's concerns and feelings related to the interactions with other clients. Ignoring or dismissing the client's concerns can further isolate the client and hinder their progress in the therapeutic environment.
d. "Everything will get beter once you get to know everyone." This response minimizes the client's feelings and does not provide immediate support or address the client's concerns. It is essential for the nurse to validate the client's emotions and explore strategies to address the issue of others making fun of the client.
In summary, the nurse should choose a response that acknowledges the client's feelings and demonstrates empathy. Validating the client's experience can help establish trust and provide a foundation for further therapeutic interventions.
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