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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Metformin is an oral medication used to treat type 2 diabetes. It should be withheld before and after a procedure that requires IV contrast dye because it can increase the risk of lactic acidosis, a serious condition caused by the buildup of lactic acid in the blood. The other medications are not contraindicated with IV contrast dye and can be given as scheduled.
Correct Answer is B
Explanation
A complete AV block (also called third-degree AV block) is a type of heart block in which there is no electrical communication between the atria and ventricles. This means that the atria and ventricles beat independently of each other, resulting in a slow and irregular pulse. A complete AV block can cause symptoms such as dizziness, fainting, chest pain, shortness of breath, and heart failure.
A permanent pacemaker is a device that sends electrical impulses to the heart to regulate its rhythm and prevent bradycardia (slow heart rate). A permanent pacemaker is indicated for clients with complete AV block and rates slower than 40/min or symptomatic bradycardia.
The other options are not indications for a permanent pacemaker. Vasovagal bradycardia is a temporary drop in heart rate and blood pressure caused by a stimulus that triggers the vagus nerve, such as pain, stress, or straining.
It usually resolves on its own or with simple measures, such as lying down or elevating the legs. Sinus tachycardia is a normal increase in heart rate in response to physical or emotional stress, such as exercise, fever, or anxiety. It usually does not require treatment unless it is caused by an underlying condition or causes symptoms.
Asymptomatic second-degree AV block is a type of heart block in which some of the electrical impulses from the atria are blocked from reaching the ventricles. It may not cause any symptoms or affect the overall heart rate. It may be benign or transient, or it may progress to a more serious type of heart block. It may require monitoring or medication, but not a permanent pacemaker unless it causes symptomatic bradycardia.
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