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

Weight gain 1.1 kg (2.4 lb) in 24 hours indicates fluid retention and possible volume overload, which can worsen kidney function and cause complications such as hypertension, pulmonary edema, and heart failure. The nurse should report this finding to the provider and monitor the client's vital signs, fluid intake and output, and electrolyte levels.

Creatinine 0.8 mL/dL is within the normal range for adults and does not indicate kidney impairment. Peripheral pulses 2+ bilaterally are normal and do not suggest any vascular problems. Urine specific gravity 1.045 is slightly high but not abnormal for a client with acute kidney failure, as it reflects the reduced ability of the kidneys to dilute urine.

A. Serum albumin level 3.9 g/dL B. Calcium level 11.5 mg/dL C. Output 200 mL more than intake over the past 12 hr D. Fasting blood glucose level 105 mg/dL.

Correct Answer is B

Explanation

A high calcium level (hypercalcemia) can indicate complications of TPN, such as bone demineralization, renal calculi, or metabolic alkalosis. The nurse should notify the provider of this finding and expect to adjust the TPN formula or administer fluids and diuretics to lower the calcium level. The other options are within normal or expected ranges for a client receiving TPN.

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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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