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 D

Explanation

Choice A rationale:

Severe headache can be a symptom of a subdural hematoma, but it is not the earliest manifestation of a change in neurological status. Other symptoms may appear before a severe headache, such as an altered level of consciousness.

Choice B rationale:

Bradycardia can occur with a subdural hematoma, especially as intracranial pressure increases. However, it is not the earliest manifestation of a change in neurological status. Changes in heart rate may occur later in the progression of the condition.

Choice C rationale:

Widened pulse pressure can also occur in patients with a subdural hematoma due to increased intracranial pressure. However, it is not the earliest manifestation of a change in neurological status. Other neurological signs would likely appear before changes in pulse pressure are evident.

Choice D rationale:

Change in level of consciousness is the earliest manifestation of a change in neurological status with a subdural hematoma. As intracranial pressure increases, the brain's functioning can be affected, leading to alterations in consciousness, ranging from mild confusion to unconsciousness.

A. Decreased NG tube drainage. B. Potassium 3.3 mEq/L. C. Increased heart rate. D. Hematocrit 46%.

Correct Answer is A

Explanation

Choice A rationale:

A decrease in NG tube drainage indicates that the client's stomach contents are not being aspirated excessively, which suggests that the IV fluids are effectively maintaining fluid volume balance. This finding is positive because it shows that the client is retaining the fluids they need, and it may also indicate improved gastrointestinal function and decreased risk of dehydration.

Choice B rationale:

The potassium level of 3.3 mEq/L (milliequivalents per liter) is low. The normal range for potassium is typically between 3.5 to 5.0 mEq/L. Hypokalemia (low potassium) can result from various factors and may cause muscle weakness, cardiac arrhythmias, and other complications. It is not a finding that indicates the effectiveness of fluid volume balance therapy.

Choice C rationale:

An increased heart rate may suggest that the client is experiencing fluid volume deficit or other physiological stress. It is not a finding that indicates the effectiveness of fluid volume balance therapy.

Choice D rationale:

A hematocrit level of 46% is within the normal range for adult males (typically around 38.8% to 50%) and indicates the proportion of red blood cells in the blood. While it can provide information about blood viscosity and hydration status, it does not directly indicate the effectiveness of fluid volume balance therapy.

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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 in an emergency department is providing care for a client who has a subdural hematoma. The nurse should identify that which of the following is the earliest manifestation of a change in neurological status?

Correct Answer is D

Explanation

A nurse is caring for a client who has an NG tube to suction and is receiving IV fluids to maintain fluid volume balance. Which of the following findings should indicate to the nurse that this therapy is effective?

Correct Answer is A

Explanation

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