A nurse is providing postoperative care for a client following a transurethral resection of the prostate to treat benign prostatic hypertrophy. Which of the following actions should the nurse take?

Maintain the client on bed rest for 48 hr following surgery.

Check the tubing for kinks and blood clots at least every 2 hr.

Irrigate the client's bladder continuously using 5% dextrose in Ringer's lactate.

Remove the catheter if the client reports severe bladder spasms.

Answer and Explanation

The Correct Answer is B

A) Maintain the client on bed rest for 48 hr following surgery: While some bed rest is recommended initially post-surgery, maintaining bed rest for 48 hours is excessive and can increase the risk of complications like deep vein thrombosis. Early mobilization is generally encouraged to enhance recovery.

B) Check the tubing for kinks and blood clots at least every 2 hr: Regularly checking the catheter tubing for kinks and blood clots is essential to ensure the continuous flow of urine and prevent catheter blockage. This can help in reducing the risk of complications such as bladder distension and urinary retention.

C) Irrigate the client's bladder continuously using 5% dextrose in Ringer's lactate: Continuous bladder irrigation is often done post-TURP to prevent clot formation, but 5% dextrose in Ringer's lactate is not the recommended solution. Typically, normal saline is used to minimize the risk of electrolyte imbalance and maintain the correct osmolarity.

D) Remove the catheter if the client reports severe bladder spasms: Severe bladder spasms can occur post-TURP, but removing the catheter is not the immediate solution. The catheter is necessary for drainage and should be managed with antispasmodic medications or adjusting the irrigation flow rather than removal.

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Correct Answer is A

Explanation

A) A client refuses to discuss treatment options with her provider following a terminal diagnosis: This behavior exemplifies denial, the first stage in Kübler-Ross's five stages of grief. In this stage, individuals are unable to accept the reality of their situation, often refusing to acknowledge the facts and avoiding discussions that might confirm the severity of their condition.

B) A client promises a higher power to live a better life if his cancer is healed: This illustrates the bargaining stage, where individuals attempt to negotiate or make deals with a higher power or fate to reverse or delay the loss or illness. They hope that by promising to change their behavior, they can influence the outcome.

C) A client withdraws from his social network following the death of a loved one: Withdrawal from social interactions is indicative of the depression stage, where individuals may feel profound sadness, hopelessness, and a desire to isolate themselves as they process the magnitude of their loss.

D) A client yells at healthcare staff following the death of a loved one: This behavior is characteristic of the anger stage, where individuals express their frustration and helplessness through anger, often directed at people around them, including healthcare providers. This stage reflects the struggle to find meaning and control in the face of loss.

A. Positive leukocyte esterase B. Increased pain upon release of abdominal palpation C. WBC 9,500 mm3 D. Pain from flexion of the left thigh when lying on the right side

Correct Answer is C

Explanation

A) Administering risperidone 25 mg IM: Administering risperidone intramuscularly is generally used for managing severe psychotic symptoms and not typically indicated for acute panic attacks. Without prior prescription or proper assessment, this action may be unsafe and inappropriate.

B) Teaching the client how to perform guided imagery: Guided imagery is an effective technique for managing anxiety over the long term, but it is not suitable for immediate relief during a severe panic attack. The client may not be able to focus or learn new techniques when experiencing extreme distress.

C) Staying with the client until the panic attack subsides: Providing immediate emotional support and reassurance by staying with the client helps reduce the intensity of the panic attack. The nurse's presence can help the client feel safer and more secure, facilitating a return to a calmer state.

D) Encouraging the client to take quick, shallow breaths: Quick, shallow breaths can exacerbate hyperventilation and increase symptoms like dizziness and lightheadedness. It is more beneficial to encourage slow, deep breathing to help regulate breathing patterns and reduce panic symptoms.

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A nurse is providing postoperative care for a client following a transurethral resection of the prostate to treat benign prostatic hypertrophy. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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