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:
Reducing the dosage of methotrexate during pregnancy is not a safe option because methotrexate is contraindicated during pregnancy due to its potential to cause birth defects and other adverse pregnancy outcomes.
Choice B reason:
While dietary modifications may be necessary during pregnancy, this is not specifically related to the use of methotrexate. The primary concern with methotrexate and pregnancy is the risk it poses to the developing fetus, not dietary interactions.
Choice C reason:
Breastfeeding while taking methotrexate is not recommended. Methotrexate can be excreted in breast milk and may harm a nursing infant.
Choice D reason:
Methotrexate should indeed be discontinued at least 3 months prior to a planned pregnancy. This is to ensure that the drug is completely cleared from the body, as it can cause serious birth defects and other pregnancy-related complications.
Correct Answer is C
Explanation
Choice A reason:
Kernig's sign is associated with meningitis and is not related to the symptoms of tingling sensations that can occur after a subtotal thyroidectomy. This sign is elicited by extending the client's leg at the knee while the hip is flexed, which would not be relevant in this case.
Choice B reason:
Brudzinski's sign is another indicator of meningitis and involves involuntary flexion of the hips and knees when attempting to flex the client's neck. Similar to Kernig's sign, it is not pertinent to the postoperative symptoms of a subtotal thyroidectomy.
Choice C reason:
Chvostek's sign is a clinical sign of existing neuromuscular irritability seen in hypocalcemia, which can occur after thyroid surgery due to accidental removal or damage to the parathyroid glands. Tapping on the facial nerve triggers twitching of the facial muscles, which correlates with the tingling sensations reported by the client.
Choice D reason:
Babinski's sign is used to assess neurological function, particularly of the central nervous system, and is not related to the symptoms of hypocalcemia. It involves stroking the sole of the foot to observe the toes' movements, which would not provide information about the tingling sensations the client is experiencing.

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