A nurse is caring for a client who is 6 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following actions should the nurse include in the plan of care? (Select all that apply.).
Encourage the client to try to void.
Secure the drainage tube to the client's thigh.
Monitor the client's urine output every 2 hr.
Administer antispasmodics for bladder spasms.
Perform intermittent bladder irrigation.
Correct Answer : A,C,D,E
Choice A rationale:
Is appropriate to assess postoperative urinary function after transurethral resection of the prostate (TURP). It helps monitor the return of normal bladder function.
Choice B rationale:
Is not necessary and could potentially cause discomfort and increased risk of tube dislodgment. Securing the tube properly to the bed or clothing is a more appropriate method.
Choice C rationale:
Is essential to assess urinary function, and fluid balance, and identify any potential complications such as urinary retention or excessive bleeding.
Choice D rationale:
Helps alleviate discomfort and prevent spasms after TURP. Bladder spasms can be common after the procedure, and antispasmodics can aid in managing them.
Choice E rationale:
Is necessary to keep the catheter patent and prevent clot formation in the urinary tract. It helps maintain proper drainage and prevents complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
10 mL/hr would be the correct infusion rate if the client was receiving the entire 10 mEq of potassium chloride in a 100 mL solution over 1 hour. However, the question asks for the rate at which to administer 10 mEq over 1 hour, which means the total volume should be 100 mL/hr.
Choice B rationale:
50 mL/hr would be the correct infusion rate if the client was receiving the entire 10 mEq of potassium chloride in a 100 mL solution over 2 hours. However, the question specifies 1 hour, so the rate should be higher.
Choice C rationale:
This is the correct answer. To administer 10 mEq of potassium chloride in 100 mL over 1 hour, the infusion pump should be set to deliver 100 mL/hr.
Choice D rationale:
500 mL/hr would be the correct infusion rate if the client was receiving the entire 10 mEq of potassium chloride in a 100 mL solution over 10 minutes (1/6th of an hour). However, the question specifies 1 hour, so the rate should be much lower.
Correct Answer is B
Explanation
Choice A rationale:
Hypertension is not a manifestation of fat overload syndrome. Fat overload syndrome occurs when the body is unable to metabolize a large amount of fat delivered by IV fat emulsions, leading to fat accumulation in organs such as the lungs, liver, and bone marrow.
Choice B rationale:
Weight gain is a common manifestation of fat overload syndrome. The excess fat not metabolized accumulates in the body, leading to weight gain and potential complications.
Choice C rationale:
Fever is not directly related to fat overload syndrome. This condition primarily involves the accumulation of fat and its related complications rather than causing fever.
Choice D rationale:
Hypoglycemia is not associated with fat overload syndrome. This condition results from low blood sugar levels and is not directly related to the administration of IV fat emulsions.
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