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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Telling the client to expect a decrease in urine output is incorrect because it may indicate dehydration, obstruction, or infection. Clients with urolithiasis should be encouraged to maintain adequate urine output to help flush out stones and prevent new stone formation. Decreased urine output can lead to complications and should be addressed promptly.
Choice B rationale
Providing the client with a high protein diet is incorrect because it may increase uric acid and calcium excretion, which can promote stone formation. Clients with urolithiasis should follow a balanced diet that is low in substances that can contribute to stone formation, such as oxalates, purines, and excessive calcium.
Choice C rationale
Maintaining the client on bed rest is incorrect because it may decrease renal perfusion and increase urinary stasis. Clients with urolithiasis should be encouraged to stay active and mobile to promote better circulation and prevent complications. Bed rest is not typically recommended unless there are specific medical indications for it.
Choice D rationale
Encouraging the client to drink 3 L of fluids per day is correct because it helps to flush out stones, prevent new stone formation, and reduce urinary concentration. Adequate hydration is essential for clients with urolithiasis to maintain proper kidney function and reduce the risk of complications. Drinking plenty of fluids helps to dilute the urine and promote the passage of stones.
Correct Answer is A
Explanation
Choice A rationale
Regular insulin is correct because it is a short-acting insulin that can be used to treat diabetic ketoacidosis (DKA). The client’s symptoms of confusion, flushed appearance, and acetone odor on the breath suggest DKA, which requires prompt treatment with insulin to lower blood glucose levels and correct metabolic acidosis. Regular insulin has a rapid onset of action and can be administered intravenously to achieve quick results.
Choice B rationale
NPH insulin is incorrect because it is an intermediate-acting insulin that is not suitable for the immediate treatment of DKA. NPH insulin has a slower onset of action and is typically used for
basal insulin coverage rather than for acute management of hyperglycemia. In cases of DKA, rapid-acting or short-acting insulin is preferred to achieve quick glucose control.
Choice C rationale
Glargine insulin is incorrect because it is a long-acting insulin that provides basal insulin coverage over 24 hours. It is not suitable for the immediate treatment of DKA, as it does not have a rapid onset of action. Glargine insulin is typically used for maintaining stable blood glucose levels over a prolonged period rather than for acute management of hyperglycemia.
Choice D rationale
Detemir insulin is incorrect because it is a long-acting insulin similar to glargine. It provides basal insulin coverage and is not suitable for the immediate treatment of DKA. Detemir insulin has a slower onset of action and is used for maintaining stable blood glucose levels rather than for rapid correction of hyperglycemia in acute situations.
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