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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. “I should practice pursed-lip breathing exercises.": This technique involves inhaling through the nose and exhaling slowly through pursed lips (as if whistling). This creates back-pressure in the airways, which keeps the bronchioles open longer during exhalation. This helps the client remove trapped carbon dioxide (CO2), reduces shortness of breath, and promotes relaxation.

B. "I will consume low-protein, low-calorie foods": Clients with COPD require adequate protein and calories to maintain muscle mass and energy for breathing. Restricting protein and calories could worsen muscle wasting and fatigue.

C. “I should do aerobic exercises once per day": While regular physical activity is beneficial, exercise should be paced and tailored to the client’s tolerance. Overexertion can exacerbate dyspnea and fatigue in COPD clients.

D. "I will increase my fluid intake to 1,700 milliliters per day.": While hydration is important to thin secretions, 1,700 mL is on the lower end of standard daily requirements for an adult. Clients with COPD are encouraged to drink 2 to 3 liters (2,000 to 3,000 mL) of fluid per day (unless contraindicated by heart failure) to help liquefy thick mucus, making it easier to cough up.

A. Recommend frequent hot baths B. Encourage the client to restrict performing range-of-motion exercises. C. Initiate contact precautions D. Monitor the client's ability to perform ADLS.

Correct Answer is D

Explanation

A. Recommend frequent hot baths: Heat exposure can worsen multiple sclerosis symptoms by increasing nerve conduction impairment. Hot baths may exacerbate fatigue, weakness, and neurologic deficits, making symptom management more difficult. Clients with MS are advised to avoid excessive heat.

B. Encourage the client to restrict performing range-of-motion exercises: Range-of-motion exercises are encouraged to maintain flexibility, prevent contractures, and support mobility in clients with multiple sclerosis. Restricting movement can lead to muscle stiffness and functional decline. Activity should be balanced with rest, not avoided.

C. Initiate contact precautions: Multiple sclerosis is a noninfectious, autoimmune neurologic disorder and does not require isolation precautions. Implementing contact precautions is unnecessary and may negatively impact the client’s psychosocial wellbeing. Standard precautions are sufficient.

D. Monitor the client's ability to perform ADLs: Multiple sclerosis can cause progressive physical and cognitive changes that affect self-care abilities. Monitoring activities of daily living helps identify functional decline early and guides referrals for occupational therapy and adaptive strategies. Ongoing assessment supports individualized care planning and safety.

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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?

Nursing Test Bank

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