A nurse is evaluating a patient who is suffering from prostatic hypertrophy.
What symptoms associated with urinary retention should the nurse anticipate? (Choose all that apply)

Choice A rationale

While monitoring abdominal girth can be important in patients with cirrhosis, especially those with ascites, it is not typically an assessment finding that requires immediate follow-up.

Choice B rationale

A blood pressure of 82/58 mm Hg is low and could indicate hypotension, which requires immediate follow-up.

Choice C rationale

A heart rate of 101/min is elevated and could indicate tachycardia, which requires immediate follow-up.

Choice D rationale

An oxygen saturation of 92% is lower than the normal range of 95% to 100%, indicating potential hypoxia, which requires immediate follow-up.

Choice A rationale

The patient has the right to withdraw their informed consent at any time, even after signing the consent form. This is a fundamental principle of patient autonomy and respect for the individual’s rights. The nurse should respect the patient’s decision and notify the surgeon that the patient wishes to withdraw informed consent for the procedure. This allows the healthcare team to reassess the situation, provide further information if necessary, and make appropriate adjustments to the care plan.

Choice B rationale

While informing the surgical team to cancel the surgery might be a subsequent step, it is not the immediate action the nurse should take. The first action should be to respect the patient’s autonomy and communicate their decision to the surgeon.

Choice C rationale

Proceeding with the preparation of the patient for the surgical procedure against their expressed wishes would be a violation of the patient’s rights. It is essential to respect the patient’s autonomy and their right to make decisions about their own healthcare.

Choice D rationale

Reminding the patient that a signed informed consent form is a legally binding document is incorrect. Informed consent is not a contract, and the patient has the right to withdraw consent at any time. The purpose of informed consent is to ensure that the patient understands the procedure, its risks and benefits, and alternatives, and makes an informed decision.