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:
Keeping artificial nails trimmed is a recommended practice in healthcare settings to maintain effective hand hygiene. Long nails can harbor bacteria and make it difficult to clean hands thoroughly. However, the CDC does not provide specific guidelines on the length of artificial nails for healthcare workers.
Choice B reason:
When caring for a client with Clostridium difficile, it is recommended to wash hands with soap and water rather than using alcohol-based hand rubs. Alcohol-based hand rubs are not effective against C. difficile spores. Therefore, thorough handwashing with soap and water is necessary to remove spores.
Choice C reason:
Chlorhexidine is an antiseptic agent that provides broad-spectrum antimicrobial activity and is recommended for hand hygiene in certain situations, such as before invasive procedures or for clients who are immunosuppressed. It is effective against a wide range of bacteria, viruses, and fungi, making it a suitable choice for immunocompromised patients to reduce the risk of infection.
Choice D reason:
The use of alcohol-based hand rubs before administering eye drops is not specifically recommended. While hand hygiene is essential before any contact with a patient, there is no particular preference for alcohol-based hand rubs in this context. The primary concern is to ensure that hands are clean to prevent contamination of the eye drops or the patient's eyes.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A reason: Thyroid stimulating hormone (TSH)
TSH levels can affect sexual function. Both hyperthyroidism and hypothyroidism can lead to ED. Hyperthyroidism can cause premature ejaculation, while hypothyroidism can reduce libido and cause ED. Therefore, assessing thyroid function is important in the evaluation of ED.
Choice B reason: Blood glucose
Diabetes mellitus is a common cause of ED. High blood glucose levels can damage blood vessels and nerves that control erection. Therefore, testing for diabetes with a blood glucose test is a standard part of the ED evaluation.
Choice C reason: Partial thromboplastin time (PTT)
PTT is not typically used to evaluate ED. It measures the time it takes for blood to clot and is usually used to assess bleeding disorders or the effectiveness of blood-thinning medication.
Choice D reason: Testosterone
Low testosterone levels can lead to a decrease in sexual desire and ED. Testosterone replacement therapy may improve the situation if this is the case. Hence, measuring testosterone levels is a critical part of the ED workup.
Choice E reason: Total cholesterol
High cholesterol can lead to atherosclerosis, which can impede blood flow to the penis and cause ED. Therefore, a lipid profile, including total cholesterol, is often checked when evaluating ED.
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