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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Providing pin care when the client is 4 hours postoperative is not appropriate. The client has just undergone skeletal traction placement, and pin care is usually initiated after 24 hours to allow for initial wound healing.

Choice B rationale:

Removing the weights from the traction while repositioning the client in bed is unsafe and not recommended. The weights should remain in place to provide continuous traction and alignment for the fractured hip.

Choice C rationale:

Assessing the client's circulation every 4 hours is essential to monitor for any signs of impaired circulation, such as swelling, pallor, or decreased pulses. Early detection of circulatory compromise is critical to prevent complications like compartment syndrome.

Choice D rationale:

Requesting the client to perform ankle exercises on the affected extremity is not appropriate after skeletal traction placement. Ankle exercises could disrupt traction and hinder the healing process of the fractured hip.

A. Hypertension. B. Weight gain. C. Fever. D. Hypoglycemia.

Correct Answer is C

Explanation

C. Fever:
Fever is a classic sign of fat overload syndrome. Fat overload syndrome occurs when the body is unable to metabolize the fat in the IV fat emulsion properly, leading to fat accumulation in tissues and organs. This can result in fever, which is one of the primary manifestations. Other signs can include respiratory distress, liver dysfunction, and changes in laboratory values, such as elevated triglycerides.

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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.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a fractured hip and was placed in skeletal traction 2 hours ago. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assessing a client who is receiving IV fat emulsion therapy. Which of the following findings should the nurse identify as a manifestation of fat overload syndrome?

Correct Answer is C

Explanation

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