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 D
Explanation
Choice A reason:
Telling a client that they will be at an increased risk of breast cancer due to fibrocystic breast changes would be incorrect. Fibrocystic breast changes are not directly linked to an increased risk of breast cancer. While the presence of complex fibrocystic changes may slightly elevate the risk, fibrocystic breasts themselves are a common and benign condition.
Choice B reason:
It is not accurate to say that the manifestations of fibrocystic breasts often get worse after menopause. In fact, fibrocystic changes are related to hormone levels, and most women experience relief from these symptoms after menopause when hormone levels decline.
Choice C reason:
Stating that menopause won't have any effect on the manifestations is also incorrect. Menopause typically leads to a decrease in hormone levels, which are associated with fibrocystic breast changes. Therefore, most women see an improvement in their symptoms after menopause.
Choice D reason:
The most appropriate response is that the manifestations usually go away after menopause. Fibrocystic breast changes are linked to hormonal fluctuations, and after menopause, when these fluctuations cease, the symptoms of fibrocystic breasts typically resolve.
Correct Answer is B
Explanation
Choice A reason:
While monitoring urinary output is important after surgery to ensure kidney function and that the urinary tract has not been compromised during surgery, it is not the immediate priority. The nurse should ensure that the client is not experiencing postoperative complications such as urinary retention, but this comes after the assessment of vital signs.
Choice B reason:
Oxygen saturation is the priority assessment for a client being admitted from the PACU following an abdominal hysterectomy. Maintaining adequate oxygenation is critical after anesthesia, as respiratory function can be compromised. The nurse must ensure the client's airway is clear and that they are receiving sufficient oxygen to prevent hypoxia and other respiratory complications.
Choice C reason:
Inspecting the abdominal dressing is necessary to check for signs of bleeding or infection at the surgical site. However, this is not the first priority upon admission from the PACU. The nurse will assess the dressing after vital signs and oxygen saturation have been addressed.
Choice D reason:
Pain management is a significant part of postoperative care, and the nurse will need to assess the client's pain level to manage it effectively. However, the immediate priority is to ensure the client's vital signs are stable, which includes oxygen saturation, before addressing pain.
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