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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) A potassium supplement: Administering a potassium supplement would be inappropriate for a client with a potassium level of 6.4 mEq/L. This level is above the normal range (3.5-5.0 mEq/L) and indicates hyperkalemia, which can have serious effects on cardiac function. Increasing potassium intake could exacerbate the condition.
B) A fiber supplement: While fiber supplements can be beneficial for overall digestive health, they do not directly address or correct an electrolyte imbalance like hyperkalemia. They are not relevant in managing elevated potassium levels.
C) An anticonvulsant: Anticonvulsants are used to manage seizure activity and are not indicated for treating hyperkalemia. They do not have any role in the regulation or management of potassium levels in the body.
D) A diuretic: Diuretics, particularly loop diuretics, are often used to help manage hyperkalemia by promoting the excretion of potassium through urine. This helps lower the elevated potassium levels in the blood and reduce the risk of complications such as cardiac arrhythmias. Therefore, administering a diuretic is an appropriate intervention for a client with a potassium level of 6.4 mEq/L.
Correct Answer is A
Explanation
A) Orthostatic hypotension: Anemia often results in decreased blood volume and oxygen-carrying capacity, which can cause orthostatic hypotension. This condition is characterized by a sudden drop in blood pressure when moving from a sitting or lying position to standing, leading to dizziness or fainting.
B) Clubbing of the nail beds: Clubbing is typically associated with chronic hypoxia and long-term respiratory or cardiovascular diseases, rather than anemia. It involves the enlargement of the fingertips and changes in the angle of the nail bed.
C) Conjunctivitis: Conjunctivitis is an inflammation of the conjunctiva, usually caused by infections, allergies, or irritants. It is not a common manifestation of anemia.
D) Heat intolerance: Heat intolerance is more commonly associated with hyperthyroidism or other metabolic disorders rather than anemia. Individuals with anemia are more likely to experience cold intolerance due to reduced oxygen delivery to tissues.
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