A nurse is caring for a client who is 2 hours postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view as an indication of a postoperative complication?
Oral temperature of 38.2°C (100.76°F)
Output of burgundy-colored urine
Pulse rate of 88/min
An urge to void despite having an indwelling urinary catheter
The Correct Answer is A
Choice A reason: An elevated oral temperature of 38.2°C (100.76°F) postoperatively can indicate an infection, which is a common complication after surgical procedures. In the context of TURP, a fever could suggest a urinary tract infection or sepsis, especially if accompanied by other symptoms such as chills or an elevated white blood cell count.
Choice B reason: The output of burgundy-colored urine can be expected in the immediate postoperative period following a TURP due to bleeding. However, it should gradually lighten in color. Persistent or worsening hematuria could indicate a complication, but it is not uncommon to see some blood in the urine shortly after the procedure
Choice C reason: A pulse rate of 88/min is within the normal range (60-100 beats per minute) and is not typically indicative of a postoperative complication. It is important to consider the patient's baseline heart rate and any other symptoms they may be experiencing.
Choice D reason: Feeling an urge to void despite having an indwelling urinary catheter can occur due to bladder spasms or irritation from the catheter itself. While uncomfortable, this sensation is not uncommon after TURP and does not necessarily indicate a complication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Bradycardia, which is a slower than normal heart rate, is not typically associated with diabetes insipidus. Diabetes insipidus primarily affects the kidneys and fluid balance in the body, leading to frequent urination and thirst but not directly affecting heart rate.
Choice B reason:
Moist mucous membranes are not expected in diabetes insipidus. In fact, due to excessive urination, a person with diabetes insipidus is more likely to experience dry mucous membranes from dehydration unless they are adequately hydrating.
Choice C reason:
Urine specific gravity 1.002 is a key finding in diabetes insipidus. This condition is characterized by the excretion of large amounts of dilute urine with low specific gravity. Normal urine specific gravity ranges from 1.005 to 1.030⁴. A value of 1.002 indicates very dilute urine, which is consistent with the inability of the kidneys to concentrate urine in diabetes insipidus.
Choice D reason:
Bounding peripheral pulses are not a finding associated with diabetes insipidus. Bounding pulses may be associated with other conditions such as fever, anemia, or hyperthyroidism but not typically with diabetes insipidus.
Correct Answer is D
Explanation
Choice A reason:
Notifying the client that they will receive a food tray in the recovery room is not typically a priority in preoperative education. Nutritional status post-surgery is important, but immediate postoperative care focuses on recovery from anesthesia and monitoring for complications.
Choice B reason:
Reminding the client that they will return to their room after surgery is part of routine information that may help orient the patient postoperatively. However, it is not a specific intervention that will aid in the recovery process or prevent complications.
Choice C reason:
Informing the client that the recovery nurse will instruct them on how to manage postoperative pain is important, but it is not the primary focus of preoperative education. Pain management is typically addressed both preoperatively and postoperatively.
Choice D reason:
Providing instructions on how to cough and deep breathe effectively is a critical component of preoperative education for clients undergoing abdominal surgery. Effective coughing and deep breathing exercises help prevent postoperative complications such as pneumonia and atelectasis by promoting lung expansion and secretion clearance.
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