A nurse is caring for a client who is two hours postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view as an indication of a postoperative complication?

Oral temperature of 38.2°C (100.76°F).

Output of burgundy colored urine.

An urge to void despite having an indwelling urinary catheter.

Pulse rate of 58/min.

Answer and Explanation

The Correct Answer is B

Choice A reason: An oral temperature of 38.2°C (100.76°F) is slightly elevated but can be expected postoperatively as the body responds to surgical stress. It is not necessarily an indication of a complication unless it rises significantly or is accompanied by other symptoms.

Choice B reason: The output of burgundy colored urine can indicate bleeding in the urinary tract, which is a potential complication after TURP. Normal urine color ranges from pale yellow to deep amber, depending on hydration levels. Burgundy colored urine postTURP could suggest the presence of blood, warranting further assessment and intervention.

Choice C reason: Feeling an urge to void despite having an indwelling urinary catheter can be uncomfortable but is not uncommon after TURP due to irritation of the bladder. It is not typically a sign of a complication unless accompanied by other symptoms such as pain or difficulty urinating once the catheter is removed.

Choice D reason: A pulse rate of 58/min is within the normal resting range for adults, which is typically 60100 beats per minute. A lower than average pulse rate postoperatively might be normal for the patient, especially if they are on medications like betablockers, or it could be a sign of a good fitness level.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D"]

Explanation

Choice A reason: Tingling in the arms can occur due to nerve compression caused by the herniated disc. This is a common symptom known as radicular pain, which can radiate from the neck down to the arms and hands.

Choice B reason: Shoulder pain is another expected finding, as the nerves affected by a cervical herniated disc can cause pain to radiate into the shoulders.

Choice C reason: Muscle spasms may be a reflexive response to the pain and inflammation caused by the herniated disc, as the body attempts to stabilize the affected area.

Choice D reason: A stiff neck can result from the muscle tension and reduced range of motion due to the pain and inflammation associated with a herniated cervical disc.

Choice E reason: Low back pain is not typically associated with a herniated cervical disc, as cervical discs are located in the neck region. Low back pain would be more indicative of a lumbar spine issue.

A. Offer the client the bedpan every 2 hours. B. Cleanse the perineum from front to back. C. Encourage fluid intake at and between meals. D. Obtain a prescription for an indwelling urinary catheter.

Correct Answer is C

Explanation

Choice A reason: Offering the bedpan every 2 hours is not specifically related to preventing urinary tract infections (UTIs) and may not be necessary unless the client has other needs that require frequent toileting.

Choice B reason: Cleansing the perineum from front to back is a standard practice to prevent the spread of bacteria from the anal area to the urethra, which can reduce the risk of UTIs.

Choice C reason: Encouraging fluid intake is crucial for clients with a spinal cord injury because it helps to flush out the urinary tract, preventing the buildup of bacteria that can cause UTIs.

Choice D reason: An indwelling urinary catheter may be necessary for a client with a T4 spinal cord injury who cannot effectively empty the bladder, but it should be used with caution as it can also increase the risk of UTIs. The decision to use an indwelling catheter should be based on a thorough assessment and consideration of all other options.

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A nurse is caring for a client who is two hours postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view as an indication of a postoperative complication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a herniated cervical intervertebral disc. Which of the following findings should the nurse expect? Select all that apply.

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care?

Correct Answer is C

Explanation

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