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?

Output of burgundy-colored urine.

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

An urge to void despite having an indwelling urinary catheter.

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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Correct Answer is D

Explanation

Choice A rationale:
A WBC count of 5,000/mm³ is within the normal range (4,500 to 11,000 cells/mm³) and is not a priority.
Choice B rationale:
A platelet count of 150,000/mm³ is within the normal range (150,000 to 450,000/mm³) and is not a priority.
Choice C rationale:
A positive Western blot test confirms HIV infection, but it is not a priority in this case.
Choice D rationale:
A CD4-T-cell count of 180 cells/mm³ is below the normal range (500 to 1,500 cells/mm³), indicating severe immune system damage in a client with HIV. This is the nurse’s priority.

A. Obtain a prescription for an indwelling urinary catheter. B. Offer the client the bedpan every 2 hr. C. Cleanse the perineum from back to front. D. Encourage fluid intake at and between meals.

Correct Answer is D

Explanation

Choice A rationale:
Indwelling urinary catheters can actually increase the risk of UTIs.
Choice B rationale:
Offering the bedpan every 2 hours may not be necessary or practical for all patients.
Choice C rationale:
Cleaning the perineum from back to front can introduce bacteria to the urinary tract, increasing UTI risk.
Choice D rationale:
Adequate hydration can help flush bacteria out of the urinary tract, reducing UTI risk.

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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?

Nursing Test Bank

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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?