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?

Increase the client's fluid intake.

Check the client's urine output.

Reposition the client in bed.

Administer PRN pain medication.

Answer and Explanation

The Correct Answer is B

Continuous bladder irrigation (CBI) is a procedure that involves instilling sterile fluid into the bladder through a three-way catheter to prevent clot formation and maintain patency after a TURP surgery. The nurse should monitor the client's urine output closely and report any signs of obstruction such as decreased urine flow, blood clots, or abdominal pain.

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Correct Answer is B

Explanation

A chest physiotherapy vest is a device that delivers high-frequency chest wall oscillation to loosen and mobilize mucus from the airways . This helps improve lung function and prevent respiratory infections in patients with cystic fibrosis, who have thick and sticky mucus production . A peak flow meter is used to measure the peak expiratory flow rate, which reflects the degree of airway obstruction in patients with asthma .

An NG tube with suction apparatus is used to decompress the stomach and remove gastric contents in patients with bowel obstruction, paralytic ileus, or gastroparesis . A chest tube with a drainage system is used to remove air or fluid from the pleural space in patients with pneumothorax, hemothorax, or pleural effusion .

A. Check the client's gag reflex. B. Inform the client they might experience a low-grade fever. C. Provide the client with sips of water. D. Instruct the client to report bleeding.

Correct Answer is A

Explanation

The nurse should assess the client's gag reflex before allowing oral intake to prevent aspiration. The client's throat may be numb after a bronchoscopy, which is a procedure that uses a thin tube with a camera and light to examine the lungs and airways . The other actions are important but not the priority.

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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?

Nursing Test Bank

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