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 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.
Correct Answer is C
Explanation
This is because the client is experiencing bradycardia, which is a slow heart rate of less than 60/min. Bradycardia can cause decreased cardiac output, which can lead to symptoms such as tremors, fainting, dizziness, chest pain, shortness of breath, and hypotension. Some causes of bradycardia are sinus node dysfunction, atrioventricular block, medication side effects, hypothyroidism, hypothermia, and increased vagal tone.
The nurse should anticipate administering atropine sulfate, which is an anticholinergic drug that blocks the action of the vagus nerve on the heart and increases the heart rate and conduction. Atropine sulfate is the first-line drug for symptomatic bradycardia and can be given intravenously or intramuscularly. The nurse should monitor the client's vital signs, cardiac rhythm, and response to the medication. The nurse should also prepare for other interventions, such as transcutaneous pacing or permanent pacemaker insertion, if atropine sulfate is ineffective or contraindicated.
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