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:
A personal trainer working with a client who has HIV is at low risk for contracting the virus. HIV is not transmitted through casual contact, sweat, or saliva. The risk would increase only if there were exposure to blood or other body fluids through an open wound or mucous membrane.
Choice B reason:
An occupational therapist working with a client who has HIV also has a low risk of contracting the virus. Similar to a personal trainer, unless there is direct exposure to blood or body fluids, the transmission risk is minimal.
Choice C reason:
A phlebotomist who collects blood from clients who have HIV is at the greatest risk among the listed individuals. Phlebotomists are healthcare professionals who are frequently exposed to blood, which is a bodily fluid that can transmit HIV if proper precautions are not taken.
Choice D reason:
A nurse who collects urine samples is at a lower risk compared to a phlebotomist. HIV is not typically transmitted through urine unless it contains blood. However, the risk is still present if there is exposure to blood-contaminated urine through cuts or mucous membranes.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A reason:
Cold extremities are not a typical symptom associated with Paget's disease of the bone. This condition usually does not affect the temperature of the limbs directly.
Choice B reason:
Skeletal pain is a common symptom in Paget's disease due to the abnormal bone remodeling process. The affected bones may become painful, especially in the pelvis, spine, skull, and long bones.
Choice C reason:
Visual loss can occur if Paget's disease affects the skull, leading to increased pressure on the nerves associated with vision. This pressure can result in visual impairment or loss.
Choice D reason:
Cranial enlargement is a possible finding in Paget's disease when the skull is involved. The abnormal bone growth can cause the skull to increase in size.
Choice E reason:
An abnormal gait may develop if Paget's disease affects the legs, causing the bones to bow and leading to difficulty walking.
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