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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Adolescents should increase their daily sodium intake to more than 2,800 milligrams.": This is incorrect because adolescents should limit sodium intake to less than 2,300 milligrams per day to reduce the risk of hypertension and cardiovascular issues. Excess sodium intake is associated with negative health outcomes rather than benefits.
B. "Adolescents should aim to consume at least 1,300 milligrams of calcium each day.": This is correct because adolescents require adequate calcium to support rapid bone growth and peak bone mass development. Meeting calcium needs during adolescence helps prevent future osteoporosis and supports overall skeletal health.
C. "Adolescent males require more iron than females due to the increase in their muscle mass.": This is incorrect because adolescent females typically require more iron than males due to menstrual blood loss. Iron is essential for hemoglobin production, and females are at higher risk for iron deficiency during adolescence.
D. "Adolescent females should consume 200 micrograms of folic acid every day.": This is inaccurate because the recommended daily allowance (RDA) for folic acid in adolescents is 400 micrograms per day, not 200. Adequate folic acid is critical for DNA synthesis and overall growth during adolescence.
Correct Answer is D
Explanation
A. "Empty the drainage bag every 12 hours.": Urine should be emptied regularly, but not on a fixed 12-hour schedule. The focus is on preventing backflow and maintaining sterility, so the bag should be emptied when it is two-thirds full or as needed, rather than strictly every 12 hours.
B. "Irrigate the indwelling urinary catheter once per shift.": Routine irrigation is not recommended for preventing catheter-associated urinary tract infections (CAUTIs) and can introduce pathogens or cause trauma. Irrigation should only be performed if specifically indicated for obstruction or provider order.
C. "Apply a topical antimicrobial ointment as part of routine catheter care.": Routine application of antimicrobial ointment is not recommended and does not prevent CAUTIs. Proper hygiene and sterile technique are more effective in infection prevention than topical agents.
D. "Keep the drainage bag below the level of the bladder.": Maintaining the drainage bag below the bladder prevents backflow of urine, which is a major risk factor for introducing bacteria into the urinary tract. This simple intervention is a key measure in reducing catheter-associated urinary tract infections.
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