A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain. Which of the following actions should the nurse take first?
Administer PRN pain medication.
Check the client's urine output.
Reposition the dent in bed
Monitor the clients fluid intake
The Correct Answer is B
Choice A rationale: Administering PRN pain medication may be necessary, but assessing the cause of the pain is the priority.
Choice B rationale: Checking the client's urine output is the first action to assess for possible complications, such as clot retention or obstruction, which could cause lower abdominal pain.
Choice C rationale: Repositioning the client in bed may be considered after assessing urine output, depending on the findings.
Choice D rationale: Monitoring fluid intake is important but is not the immediate action needed to address the reported pain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: A client who has an ileostomy will have liquid stools that drain into an ostomy bag.
Choice B rationale: Eating a high-fiber diet may not be suitable for a client with an ileostomy, as it can increase stool output.
Choice C rationale: The client should avoid high-fiber foods, which can cause obstruction, and should empty the bag when it is one-third to one-half full to prevent leakage and skin irritation.
Choice D rationale: Taking a laxative when constipated is not relevant for a client with an ileostomy. Laxatives can cause dehydration and electrolyte imbalance.
Correct Answer is B
Explanation
Choice A rationale: Administering PRN pain medication may be necessary, but assessing the cause of the pain is the priority.
Choice B rationale: Checking the client's urine output is the first action to assess for possible complications, such as clot retention or obstruction, which could cause lower abdominal pain.
Choice C rationale: Repositioning the client in bed may be considered after assessing urine output, depending on the findings.
Choice D rationale: Monitoring fluid intake is important but is not the immediate action needed to address the reported pain.
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