A nurse is planning care for a client who is 2 hours postoperative following a transurethral resection of the prostate (TURP). The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?
Restrict the client's oral fluid intake.
Remind the client he might feel a constant urge to void.
Monitor the client's urine output every 6 hours.
Weigh the client every evening.
The Correct Answer is B
Choice A reason:
Restricting the client's oral fluid intake is not typically recommended as part of postoperative care following TURP. In fact, maintaining adequate hydration is important to help flush the bladder and prevent clot formation.
Choice B reason:
It is common for clients to feel a constant urge to void due to the irritation of the bladder from the catheter and the continuous bladder irrigation. Reminding the client that this sensation is normal and expected can help alleviate anxiety and provide reassurance.
Choice C reason:
Monitoring the client's urine output is important to ensure that the bladder irrigation is effective and that there are no signs of obstruction. However, it should be done more frequently than every 6 hours, especially in the immediate postoperative period, to promptly detect any complications.
Choice D reason:
Weighing the client every evening is not directly related to the management of continuous bladder irrigation. While monitoring weight can be part of overall postoperative care, it does not address the specific needs related to TURP and continuous bladder irrigation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Bradycardia, which is a slower than normal heart rate, is not typically associated with diabetes insipidus. Diabetes insipidus primarily affects the kidneys and fluid balance in the body, leading to frequent urination and thirst but not directly affecting heart rate.
Choice B reason:
Moist mucous membranes are not expected in diabetes insipidus. In fact, due to excessive urination, a person with diabetes insipidus is more likely to experience dry mucous membranes from dehydration unless they are adequately hydrating.
Choice C reason:
Urine specific gravity 1.002 is a key finding in diabetes insipidus. This condition is characterized by the excretion of large amounts of dilute urine with low specific gravity. Normal urine specific gravity ranges from 1.005 to 1.030⁴. A value of 1.002 indicates very dilute urine, which is consistent with the inability of the kidneys to concentrate urine in diabetes insipidus.
Choice D reason:
Bounding peripheral pulses are not a finding associated with diabetes insipidus. Bounding pulses may be associated with other conditions such as fever, anemia, or hyperthyroidism but not typically with diabetes insipidus.
Correct Answer is B
Explanation
While GERD (gastroesophageal reflux disease) can be exacerbated by hormone therapy due to its potential effect on the lower esophageal sphincter, it is not typically a contraindication for HT unless the GERD is severe and not well controlled with treatment.
Choice B reason:
A history of breast cancer is a contraindication for hormone therapy. Estrogen can stimulate the growth of hormone receptor-positive breast cancers, and therefore, HT is not recommended for individuals with a current or past history of breast cancer.
Choice C reason:
COPD (chronic obstructive pulmonary disease) is not a contraindication for HT. While patients with COPD may have other comorbidities that could affect the safety of HT, COPD alone does not preclude the use of hormone therapy.
Choice D reason:
Dermatitis, or inflammation of the skin, is not a contraindication for HT. Skin conditions are not typically affected by hormone therapy, and HT may sometimes be beneficial for skin health during menopause.
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