A nurse is caring for a client who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse to report to the provider?
Emesis of 100 mL
Oral temperature of 37.5" C (99.5° F)
Pain level of 4 on a 0 to 10 rating scale
Thick, red-colored urine
The Correct Answer is D
a. Emesis of 100 mL: While emesis is a concern, the priority is to address potential complications related to the surgical procedure first.
b. Oral temperature of 37.5" C (99.5° F): This temperature is within a normal range, and it is not an immediate concern.
c. Pain level of 4 on a 0 to 10 rating scale: Pain is important to address, but the priority is to assess for potential complications such as bleeding or infection.
d. Thick, red-colored urine: This finding suggests the possibility of bleeding, which could be a complication of the TURP procedure. It is the priority finding to report to the provider for further evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. Asthma: While asthma can cause dyspnea and fatigue, it is not typically associated with tachycardia and edema.
b. Heart failure: Heart failure is characterized by symptoms such as dyspnea, fatigue,
tachycardia, and edema. Tachycardia may be a compensatory response to maintain cardiac output, and edema can result from fluid retention.
c. Aortic valve regurgitation: Aortic valve regurgitation may cause symptoms such as dyspnea and fatigue, but it is not typically associated with tachycardia and edema.
d. Aortic stenosis: Aortic stenosis may lead to symptoms such as dyspnea, but tachycardia and edema are not typical features of aortic stenosis.
Correct Answer is C
Explanation
a. Type A: Type A blood may not be compatible with the client's blood type, and it is not considered a universal donor.
b. Type B: Similar to Type A, Type B blood may not be compatible with the client's blood type, and it is not considered a universal donor.
c. Type O: Type O negative blood is considered the universal donor for packed red blood cells. It can be administered to individuals with any blood type in an emergency situation.
d. Type AB: While Type AB is considered the universal recipient for blood transfusions, it is not the universal donor.
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