A nurse is caring fora postoperative client following a perineal prostatectomy.

For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Irrigate indwelling urinary catheter with 50 mL of normal saline.

Apply warm compresses to the incision site.

Maintain bed rest for 2 days postoperatively.

Place a blanket roll under the client's knees while in bed.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"}}

Rationale

• Irrigate indwelling urinary catheter with 50 mL normal saline: Following perineal prostatectomy, bladder spasms, pink urine, and a sensation of fullness can indicate catheter blockage from clots. Gentle irrigation with a small volume ensures catheter patency and relieves obstruction. The client’s decreasing urine output despite increased intake further supports the need for irrigation. Restoring flow prevents retention and reduces discomfort from bladder spasms.

• Apply warm compresses to the incision site: Heat increases vasodilation and can worsen postoperative bleeding in a highly vascular perineal area. A prostatectomy incision requires protection from excessive warmth to reduce hemorrhage risk. Additionally, warm compresses could increase swelling and discomfort.

• Maintain bed rest for 2 days postoperatively: Early ambulation is essential to prevent postoperative complications such as DVT, which is especially important given the client’s history of thrombosis. This client is already independently ambulating, which should be encouraged. Bed rest would increase clot formation risk and impair bowel function, worsening constipation and pain.

• Place a blanket roll under the client’s knees while in bed: Placing pillows or rolls under the knees promotes venous stasis and increases DVT risk, which is dangerous for this client with a past history of thrombosis. Knee flexion also strains the perineal surgical area and may increase pain. Maintaining legs flat encourages optimal circulation and reduces risk of clot formation.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Denial: Denial is an expected initial stage of grief in response to terminal illness. Clients may have difficulty accepting the diagnosis and may refuse to believe the reality of their condition as a coping mechanism.

B. Reorganization: Reorganization is a later stage of grief associated with adapting to loss after bereavement. It is not typically part of the immediate response to a terminal diagnosis in the dying process.

C. Numbing: Numbing is more commonly associated with acute grief reactions following sudden loss, rather than the anticipatory grief experienced after a terminal diagnosis.

D. Reinvesting: Reinvesting refers to redirecting emotional energy into new relationships or activities after loss. This stage occurs after bereavement and is not part of the expected stages of grief during the dying process.

A. Fundus 2 fingerbreadths above the umbilicus B. Uterine atony C. Fundus firm and to the right of the abdominal midline D. Two voids of 150 mL each over the past 2 hr

Correct Answer is D

Explanation

A. Fundus 2 fingerbreadths above the umbilicus: This finding relates to uterine involution rather than urinary elimination. While important for postpartum assessment, it does not indicate restored bladder function.

B. Uterine atony: Uterine atony is a complication that increases the risk of postpartum hemorrhage. It does not provide information about the client’s ability to void and requires separate monitoring and intervention.

C. Fundus firm and to the right of the abdominal midline: A firm but displaced fundus may indicate a full bladder, which can interfere with urination. This finding suggests bladder distention rather than restored urinary elimination.

D. Two voids of 150 mL each over the past 2 hr: Adequate urine output in regular intervals indicates that the bladder is emptying effectively. Measuring volume and frequency confirms the client’s ability to eliminate urine has been restored postpartum.

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A nurse is caring fora postoperative client following a perineal prostatectomy. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a new diagnosis of terminal advanced lung cancer. Which of the following is an expected stage of grief based on the stages of dying?

Correct Answer is A

Explanation

A nurse is caring for a client who is postpartum and reports difficulty voiding. Which of the following findings should indicate to the nurse that the client's ability to eliminate urine from the bladder is restored?

Correct Answer is D

Explanation

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A nurse is caring fora postoperative client following a perineal prostatectomy.

For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.