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.
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).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Hemorrhagic stroke is characterized by sudden, severe headache, vomiting, and a significant increase in blood pressure, all of which are present in the client. This type of stroke occurs when a weakened blood vessel ruptures and bleeds into the surrounding brain.
Choice B rationale:
Thrombotic stroke is caused by a clot that develops in a blood vessel within the brain. It typically presents with less severe symptoms and a gradual onset, not a sudden one.
Choice C rationale:
Embolic stroke is caused by a clot that travels to the brain from another part of the body. Like thrombotic stroke, it typically has a more gradual onset.
Choice D rationale:
Transient ischemic attack (TIA) is a temporary blockage of blood flow to the brain. It usually lasts less than an hour and does not cause permanent damage.
Correct Answer is B
Explanation
Choice A rationale:
Placing the client back in bed during a seizure could lead to injury.
Choice B rationale:
Placing the client on his side, specifically the left side, allows for the tongue to fall forward, preventing aspiration.
Choice C rationale:
Holding the client’s arms and legs from moving could cause harm to the client or nurse.
Choice D rationale:
Inserting a tongue blade in the client’s mouth could cause injury to the client’s oral cavity.
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