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 D
Explanation
As individuals age, there is a natural decline in kidney function. This can result in a reduced ability to filter and excrete medications and their metabolites from the body. The decreased kidney function can lead to a longer half-life of medications, increased drug accumulation, and an increased risk of adverse drug reactions. It is important for the nurse to adjust medication dosages and frequencies based on the individual's renal function to prevent drug toxicity.
Increased liver function: Aging is associated with a gradual decline in liver function. While there may be some individual variations, in general, liver function decreases rather than increases with age. However, changes in liver function can affect the metabolism and elimination of medications. Some medications may require dosage adjustments based on liver function, but it is not a common physiological change in older adults.
Increased metabolism: Aging is generally associated with a decrease in metabolism rather than an increase. The metabolic rate tends to slow down with age, which can affect the pharmacokinetics of medications. Slower metabolism can result in medications taking longer to be metabolized and cleared from the body, potentially leading to prolonged drug effects.
Decreased pulmonary function: While it is true that lung function decreases with age, the impact on medication administration is not as significant compared to kidney function. Medications are usually administered through non-pulmonary routes (e.g., oral, intravenous, transdermal), and decreased pulmonary function primarily affects the absorption of inhaled medications. However, certain respiratory conditions or compromised lung function may influence medication choices or require adjusted dosing.
Correct Answer is C
Explanation
Answer: C. Change the perineal pad with each void.
Rationale:
A) Cleanse the perineal area from back to front: Cleansing from back to front is not recommended as it increases the risk of introducing bacteria from the anal area to the perineal wound, potentially leading to infection. The correct technique is front-to-back cleansing to prevent contamination.
B) Wash the perineal area with povidone-iodine twice daily: Povidone-iodine is not typically recommended for regular perineal care postpartum, as it can disrupt normal flora and potentially irritate the healing tissues. Using warm water and mild soap is safer for cleansing the area.
C) Change the perineal pad with each void: Changing the perineal pad with each void helps maintain cleanliness and reduces moisture in the perineal area, decreasing the risk of infection and promoting comfort during the healing process of an episiotomy.
D) Wipe the perineal area with a soft cloth: Wiping the area can disrupt the stitches and may cause discomfort. Instead, clients are usually advised to gently pat dry or use a squirt bottle to cleanse, which reduces pressure on the healing tissue.
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