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A nurse is caring for a client who is 2 hr postoperative following a transurethral resection of the prostate (TURP) gland.

Which of the following assessments should the nurse view to be an indication of a postoperative complication?

A.

Output of burgundy-colored urine.

B.

Oral temperature of 38.2° C (100.76° F).

C.

An urge to void despite having an indwelling urinary catheter.

D.

Pulse rate of 88/min.

Answer and Explanation

The Correct Answer is A

Choice A rationale:
Output of burgundy colored urine can indicate bleeding, which is a complication after TURP.
Choice B rationale:
A slight fever might be normal postoperatively. However, a high fever could indicate an infection.
Choice C rationale:
An urge to void despite having an indwelling urinary catheter can be a normal sensation following surgery.
Choice D rationale:
A pulse rate of 88/min is within the normal range (60-100/min).
 


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Related Questions

Correct Answer is C

Explanation

Choice A rationale:
Sleeping on the abdomen could put pressure on the eye and disrupt healing.
Choice B rationale:
White drainage could indicate an infection, which should be reported immediately.
Choice C rationale:
Lifting heavy objects can increase intraocular pressure, potentially damaging the surgical site.
Choice D rationale:
Bending at the waist can also increase intraocular pressure.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

  • Vision (Blurred)

    • Interpretation: Potential worsening condition
    • Rationale: Blurred vision can be a sign of lithium toxicity. Despite the lithium level improving, this symptom indicates that neurotoxicity may still be present.

  • Lithium Level (1.2 mEq/L)

    • Interpretation: Potential improvement
    • Rationale: The lithium level has decreased from 1.8 mEq/L (toxic) to 1.2 mEq/L, which is within the therapeutic range (0.6-1.2 mEq/L). This indicates that treatment to lower lithium toxicity is effective.

  • Urine Output (40 mL/hr)

    • Interpretation: Potential improvement
    • Rationale: A urine output of 40 mL/hr is within the acceptable range (normal is greater than 30 mL/hr), suggesting that kidney function is adequate and not compromised by lithium toxicity.

  • Mucous Membranes (Pale, Dry)

    • Interpretation: Potential worsening condition
    • Rationale: Pale, dry mucous membranes suggest dehydration, which can increase the risk of lithium toxicity and negatively affect overall health.

  • Vital Signs (BP 88/50 mm Hg, Pulse 96/min)

    • Interpretation: Potential worsening condition
    • Rationale: The drop in blood pressure from 130/84 mm Hg to 88/50 mm Hg indicates hypotension. This could be related to dehydration or lithium toxicity, and it requires follow-up as the condition is deteriorating.

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