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 A

Explanation

A platelet count of 95,000/mm is below the normal range of 150,000 to 400,000/mm and indicates thrombocytopenia, which increases the risk of bleeding during surgery. The nurse should report this value to the surgeon and anticipate interventions such as transfusion of platelets or postponement of surgery. The other values are within normal limits and do not require immediate attention.

A. Increased heart rate B. Generalized abdominal pain C. Cloudy effluent D. Fever

Correct Answer is C

Explanation

This is because peritonitis is an infection of the peritoneal cavity that can occur as a complication of peritoneal dialysis. Peritonitis can cause inflammation and irritation of the peritoneum, which can lead to cloudy or milky appearance of the dialysate fluid that drains out of the abdomen (also known as effluent). Cloudy effluent is often the first and most reliable sign of peritonitis in peritoneal dialysis patients. Other signs and symptoms of peritonitis may include increased heart rate, generalized abdominal pain, fever, nausea, vomiting, loss of appetite, and malaise.

The nurse should instruct the client and his partner to inspect the effluent for clarity every time they perform an exchange and to report any changes to their health care provider immediately. The nurse should also teach them how to prevent peritonitis by following strict aseptic technique when handlingcatheters and supplies, washing hands before and after each exchange, wearing a mask during exchanges, and storing supplies in a clean and dry place.

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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

Naxlex Comprehensive Predictor Exams

A nurse is reviewing laboratory results for four clients who are scheduled for surgery. Which of the following laboratory values should the nurse report to the surgeon?

Correct Answer is A

Explanation

A nurse is teaching a client and his partner about performing peritoneal dialysis at home. When discussing peritonitis, which of the following manifestations should the nurse identify as the earliest indication of this complication?

Correct Answer is C

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