A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour.

Which of the following actions should the nurse take first?

The correct answer is: A

Choice A Reason: Hypokalemia refers to a lower-than-normal level of potassium in the bloodstream. Normal potassium levels are typically between 3.5 and 5.0 mEq/L. In the context of nephrotic syndrome and high-dose corticosteroid therapy, hypokalemia can occur due to increased urinary potassium losses caused by corticosteroid-induced alterations in kidney function. Corticosteroids can promote the excretion of potassium, leading to a deficiency.

Choice B Reason: Hypomagnesemia is a condition where there is a magnesium deficiency in the blood, with normal levels usually ranging between 1.7 and 2.2 mg/dL. While it can occur in nephrotic syndrome due to urinary losses of proteins that bind magnesium, it is not typically associated with corticosteroid therapy. Therefore, it is less likely to be monitored in this specific scenario.

Choice C Reason: Hypermagnesemia indicates an abnormally high level of magnesium in the blood. This condition is relatively rare and is not commonly associated with nephrotic syndrome or corticosteroid therapy. It is more often related to renal failure or excessive intake of magnesium-containing medications or supplements.

Choice D Reason: Hyperkalemia is characterized by an elevated level of potassium in the blood, with normal levels being 3.5 to 5.0 mEq/L. While hyperkalemia can occur in nephrotic syndrome due to the loss of albumin in the urine, which can affect calcium and potassium binding, corticosteroid therapy typically causes a decrease in potassium levels, making hypokalemia a more relevant concern in this context.

Choice A rationale:
Restlessness is a common early sign of increased intracranial pressure (ICP). It can be caused by the brain’s response to the pressure, leading to agitation and restlessness.
Choice B rationale:
Tachycardia, or a rapid heart rate, is not typically a sign of increased ICP. It can be a response to other factors such as pain, anxiety, or certain medications.
Choice C rationale:
Hypotension, or low blood pressure, is not typically a sign of increased ICP. In fact, hypertension, or high blood pressure, is more commonly associated with increased ICP2.
Choice D rationale:
Amnesia, or memory loss, is not typically a sign of increased ICP. It can be a result of the brain injury itself, but it is not a direct indicator of increased ICP2.