A nurse is collecting data on a client who is postoperative following a transurethral resection of the prostate (TURP). The nurse should recognize which of the following findings is the priority?
The client has small blood clots in his urinary catheter.
The client reports a continuous urge to void.
The client reports burning around the urinary catheter.
The client has bright red urine in his urinary catheter.
The Correct Answer is D
Choice A rationale
Small blood clots in the urinary catheter are common after TURP and usually resolve on their own. They are not typically a cause for immediate concern unless they persist or cause blockage.
Choice B rationale
A continuous urge to void is a common symptom after TURP due to irritation of the bladder and urethra. It is uncomfortable but not usually a priority concern.
Choice C rationale
Burning around the urinary catheter can occur due to irritation or infection. While it needs to be addressed, it is not the most critical finding.
Choice D rationale
Bright red urine in the urinary catheter indicates active bleeding, which can be a sign of a serious complication such as hemorrhage. This requires immediate attention to prevent further blood loss and potential shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Cabbage is not a significant source of potassium. While it is a healthy vegetable, it does not provide the necessary potassium to help raise serum potassium levels.
Choice B rationale
Cheddar cheese is also not a high-potassium food. It is rich in calcium and protein but does not significantly contribute to potassium intake.
Choice C rationale
Bananas are well-known for their high potassium content. Including bananas in the diet can help increase serum potassium levels, which is beneficial for a client taking furosemide, a diuretic that can cause potassium loss.
Choice D rationale
Potatoes are another excellent source of potassium. However, the question specifies choosing one food, and bananas are a more commonly recommended option for increasing potassium intake.
Correct Answer is B
Explanation
Choice A rationale
Placing a sandbag to the lateral calf is not an effective method to prevent hip dislocation. Sandbags are typically used to provide support and immobilization in other contexts, such as stabilizing fractures. They do not provide the necessary support to prevent hip dislocation after a total hip arthroplasty.
Choice B rationale
Placing a wedge pillow between the legs is an effective method to prevent hip dislocation after a total hip arthroplasty. The wedge pillow helps to maintain proper alignment of the hip joint by keeping the legs abducted (apart) and preventing adduction (bringing the legs together), which can cause dislocation.
Choice C rationale
Placing a trochanter roll against the thigh is not specifically aimed at preventing hip dislocation. Trochanter rolls are used to prevent external rotation of the hip in patients who are immobile, but they do not provide the necessary support to prevent dislocation after hip surgery.
Choice D rationale
Placing a footboard on the bed is not an effective method to prevent hip dislocation. Footboards are used to provide support to the feet and prevent foot drop in bedridden patients, but they do not address the risk of hip dislocation.
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