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 A
Explanation
A. Observe the client during and after meals: Monitoring the client for bingeing or purging behaviors is the priority intervention because it addresses immediate safety and physical health risks, such as electrolyte imbalances. Direct observation prevents harmful behaviors and allows timely intervention.
B. Refer the client to a support group for clients who have eating disorders: Referral is important for long-term psychosocial support, but it does not address immediate risk or safety concerns during meals.
C. Instruct the client about effective coping strategies: Teaching coping strategies is beneficial for long-term management, but ensuring safety during meals takes precedence in the nursing process.
D. Suggest that the client assist with meal planning: Involving the client in meal planning promotes autonomy and engagement in treatment, but it is not the first action when immediate monitoring is required to prevent harmful behaviors.
Correct Answer is B
Explanation
A. “We can accept verbal consent unless the surgical procedure is an emergency”: Verbal consent is generally insufficient for surgical procedures except in true emergencies when the client is unable to consent. Surgical informed consent typically requires written documentation to meet legal and ethical standards.
B. “You can sign the informed consent form after the provider explains the pros and cons of the procedure”: Informed consent requires that the provider explain the nature of the procedure, risks, benefits, and alternatives before the client signs. The nurse’s role is to reinforce understanding and verify that the consent is given voluntarily.
C. “A family member must witness your signature on the informed consent form.”: A family member is not required to witness informed consent. A nurse or authorized healthcare staff may serve as a witness to the client’s signature, confirming that it was signed voluntarily.
D. “We require informed consent for all routine treatments.”: Routine treatments and nursing care generally fall under implied consent. Formal informed consent is required for invasive procedures, surgeries, and treatments with significant risk, not for all routine care.
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