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 D
Explanation
Choice A rationale
A high protein diet is not recommended for clients with biliary colic from chronic cholecystitis as it can increase bile production and exacerbate symptoms.
Choice B rationale
A high fiber diet is beneficial for overall health but does not specifically address the needs of clients with biliary colic.
Choice C rationale
A low sodium diet is beneficial for overall health but does not specifically address the needs of clients with biliary colic.
Choice D rationale
A low fat diet is recommended for clients with biliary colic from chronic cholecystitis as it reduces the workload on the gallbladder and decreases the risk of gallstone formation.
Correct Answer is D
Explanation
Choice A rationale
Administering the medication with each meal is incorrect. Clopidogrel can be taken with or without food, and there is no specific requirement to administer it with each meal. The primary concern with clopidogrel is monitoring for signs of bleeding.
Choice B rationale
Initiating contact precautions is incorrect. Clopidogrel is an antiplatelet medication and does not require contact precautions. Contact precautions are typically used for infections that can be transmitted through direct or indirect contact.
Choice C rationale
Having suction equipment at the bedside is incorrect. Suction equipment is not necessary for clients taking clopidogrel. The primary concern with clopidogrel is monitoring for signs of bleeding, not respiratory issues.
Choice D rationale
Monitoring the client for black, tarry stools is correct. Clopidogrel increases the risk of bleeding, and black, tarry stools can be an indication of gastrointestinal bleeding. It is important to monitor for this adverse effect to ensure the client’s safety.
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