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 B
Explanation
Choice A rationale:
Hemoptysis, which is the coughing up of blood, is not typically associated with a urinary tract infection (UTI). It is more commonly related to respiratory or pulmonary issues.
Choice B rationale:
Hematuria, the presence of blood in the urine, is a common finding in a UTI. Inflammation and infection in the urinary tract can lead to the presence of blood cells in the urine.
Choice C rationale:
Hyperglycemia, an elevated blood glucose level, is not directly related to a UTI. It may be seen in individuals with diabetes, but it is not a typical finding in a UTI.
Choice D rationale:
Hypocalcemia, a low level of calcium in the blood, is not a characteristic finding in a UTI. UTIs primarily affect the urinary system and do not directly involve calcium metabolism.
Correct Answer is B
Explanation
Let's break down the calculation:
Given:
- Patient weight: 154 lbs
- Enoxaparin dosage: 0.75 mg/kg
- Available enoxaparin: 60 mg/0.6 mL
Step 1: Convert pounds to kilograms:
- 1 lb is approximately 0.4536 kg
- So, 154 lbs = 154 * 0.4536 kg/lb = 69.85 kg (approximately 70 kg)
Step 2: Calculate the total dose of enoxaparin:
- Desired dose = 0.75 mg/kg * 70 kg = 52.5 mg
Step 3: Determine the volume to administer:
- We have enoxaparin 60 mg/0.6 mL
- To find the volume for 52.5 mg:
- (52.5 mg / 60 mg) * 0.6 mL = 0.525 mL
- Rounded to the nearest tenth, this is 0.5mL.
Therefore, the nurse should administer 0.5mL of enoxaparin
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