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 A
Explanation
Choice A reason:
Blood in the urine (hematuria) or semen (hematospermia) can be a sign of advanced prostate cancer. This symptom occurs when the cancer affects the urinary or reproductive tracts, causing bleeding. It is a direct result of the tumor invading nearby tissues or structures.
Choice B reason:
While anemia can be associated with chronic diseases like cancer, it is not a direct manifestation of the advancing disease process of prostate cancer. Anemia in cancer patients is often multifactorial, including chronic inflammation, nutritional deficiencies, or treatment-related side effects.
Choice C reason:
A dark-colored or elevated lesion is not typically associated with prostate cancer. Such lesions are more commonly related to skin cancers or other dermatological conditions.
Choice D reason:
An enlarged liver or gallbladder can be a sign of metastasis in advanced cancer cases, including prostate cancer. However, it is less specific than blood in the urine or semen and can be caused by a variety of other conditions.
Correct Answer is A
Explanation
Choice A reason:
Difficulty with abduction of the arm at the shoulder is a common finding in clients with a rotator cuff injury. The rotator cuff is a group of muscles and tendons that stabilize the shoulder joint and facilitate its movement. When these muscles or tendons are injured, movements such as lifting the arm away from the body (abduction) can become painful and difficult.
Choice B reason:
Alteration in the contour of the joint is not typically associated with a rotator cuff injury. This finding is more indicative of conditions that cause changes in the bone structure, such as arthritis or dislocation.
Choice C reason:
A positive Tinel's sign is used to diagnose nerve compression or nerve damage, particularly in conditions like carpal tunnel syndrome. It is not a test used to assess rotator cuff injuries.
Choice D reason:
A negative drop arm test would suggest that the client does not have a rotator cuff injury. The drop arm test is performed by having the client lift the arm to 90 degrees and then slowly lower it. If the client can control the motion and lower the arm smoothly, the test is negative. A positive drop arm test, where the client cannot control the descent of the arm, would indicate a rotator cuff injury.
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