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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason:
It is important to keep a Plaster of Paris cast dry because moisture can weaken the cast and irritate the skin underneath. Therefore, the cast should be covered while showering to prevent it from getting wet.

Choice B reason:
Applying ice to the foot after walking can help reduce swelling and provide pain relief. It is a common recommendation for managing discomfort associated with a walking cast. The ice should be applied over the cast at the level of the injury for 15-30 minutes, repeating every few hours for the first few days.

Choice C reason:
While a musty odor can develop over time due to sweat and lack of air circulation, it is not necessarily normal and could indicate a problem such as an infection. If there is a persistent unpleasant odor, it should be evaluated by a healthcare provider.

Choice D reason:
Numbness or pain in the toes can be a sign of compromised circulation or nerve compression and should be reported immediately. It is crucial to monitor for any changes in sensation or increased pain, as these could indicate a serious issue that requires medical attention.

A. Clay-colored stools B. Nystagmus C. Tinnitus D. Respiratory depression

Correct Answer is C

Explanation

Choice A reason:
Clay-colored stools are typically associated with issues in the biliary system, such as bile duct obstruction or liver infections, and not directly with aspirin use. Aspirin does not typically cause a change in stool color unless there is gastrointestinal bleeding, which would more likely result in black, tarry stools.

Choice B reason:
Nystagmus, which is a vision condition characterized by repetitive, uncontrolled eye movements, is not a known side effect of aspirin. This condition is more commonly associated with neurological disorders, certain medications, or alcohol intoxication.

Choice C reason:
Tinnitus, or ringing in the ears, is a recognized adverse effect of aspirin, especially when taken in high doses or for a prolonged period. It occurs due to aspirin's effect on the inner ear's cochlear cells and can be a sign of salicylate toxicity.

Choice D reason:
Respiratory depression is not a typical side effect of aspirin. Aspirin can cause respiratory alkalosis in cases of overdose, but it does not depress respiration. Instead, it may cause hyperventilation due to stimulation of the respiratory center in the brain.

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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?

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