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 ["B","C","D"]
Explanation
Choice A rationale
Polyuria (frequent urination) is not a typical manifestation of hypoglycemia. It is more commonly associated with hyperglycemia (high blood sugar levels)15.
Choice B rationale
Sweating is a common symptom of hypoglycemia. It occurs as the body’s response to low blood sugar levels, triggering the release of adrenaline.
Choice C rationale
Blurry vision can occur during hypoglycemia due to the lack of glucose available for the proper functioning of the eyes.
Choice D rationale
Tachycardia (rapid heartbeat) is a common symptom of hypoglycemia. It occurs as the body’s response to low blood sugar levels, triggering the release of adrenaline.
Choice E rationale
Polydipsia (excessive thirst) is not a typical manifestation of hypoglycemia. It is more commonly associated with hyperglycemia.
Correct Answer is A
Explanation
Choice A rationale
Rifampin can cause discoloration of body fluids, including tears, which can stain contact lenses. Therefore, it is recommended to wear glasses instead of contacts while taking this medication.
Choice B rationale
A yellow tint to the skin is not an expected reaction to rifampin. This could indicate jaundice, a sign of liver dysfunction, which requires immediate medical attention.
Choice C rationale
Lifelong treatment with rifampin is not necessary. The typical duration of treatment for active tuberculosis is 6 to 9 months.
Choice D rationale
Rifampin does not cause amenorrhea when taken with oral contraceptives. However, it can reduce the effectiveness of oral contraceptives, so additional contraceptive methods should be used.
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