A nurse is collecting data from a client who is 1 day postoperative following a transurethral resection of the prostate. Which of the following findings should the nurse report to the provider?
Frequent urge to urinate
Occasional small clots in the urine
Dark red urine
Urine output of 300 mL over 8 hr
The Correct Answer is C
A. Frequent urge to urinate: Urinary frequency and urgency are expected findings after TURP due to bladder and urethral irritation from surgery and catheterization. These sensations typically improve as inflammation subsides and do not require immediate provider notification.
B. Occasional small clots in the urine: Small clots can be expected during the early postoperative period following TURP as the prostatic tissue heals. Continuous bladder irrigation often helps flush these clots, and their presence alone does not indicate a complication unless they become large or obstruct urine flow.
C. Dark red urine: Dark red urine indicates active bleeding and is an abnormal finding 1 day post-TURP. This suggests possible hemorrhage or inadequate hemostasis and requires prompt provider notification to prevent complications such as clot retention or hypovolemia.
D. Urine output of 300 mL over 8 hr: This urine output averages approximately 37.5 mL/hr, which is within acceptable limits for an adult postoperative client. Adequate output suggests sufficient renal perfusion and does not require immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B,A,D,C
Explanation
A. Examine personal thoughts and feelings about meeting the client: The nurse should first engage in self-reflection to identify any biases, anxieties, or expectations. This helps ensure that personal feelings do not interfere with establishing a therapeutic and professional relationship with the client.
B. Introduce self and set goals for the relationship: After self-reflection, the nurse introduces themselves to the client and collaboratively establishes the goals and boundaries of the therapeutic relationship. This step builds trust and sets clear expectations for interactions.
C. Assist the client with identifying problem-solving techniques: Once the relationship is established, the nurse helps the client develop coping and problem-solving strategies. This step supports the client’s growth, autonomy, and ability to manage challenges effectively.
D. Summarize the achievement of goals that have been met: At the conclusion of the therapeutic relationship, the nurse reviews progress with the client and summarizes goals that were achieved. This reinforces accomplishments, encourages continued growth, and provides closure to the relationship.
Correct Answer is A
Explanation
A. “It is your choice to share personal information during group therapy.”: This statement supports client autonomy by emphasizing the client’s right to make decisions about their own participation and what personal information to disclose. Respecting autonomy involves allowing clients to make informed choices about their care and interactions.
B. "I will only discuss your medical information with the health care team.": This reflects the ethical principle of confidentiality, protecting privacy, but does not directly address autonomy.
C. “I will be truthful when answering questions about your treatment”: Truthfulness relates to veracity, ensuring honesty in the nurse-client relationship, but does not specifically promote autonomy.
D. "The nursing staff here will provide you with nonjudgmental care”: Providing nonjudgmental care supports beneficence and a therapeutic environment but does not directly empower the client to make their own decisions.
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