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 ["B","C","E"]

Explanation

A) Urticaria:
Urticaria, or hives, is a skin reaction characterized by itchy, raised welts. It is not typically associated with a small bowel obstruction, which primarily affects the gastrointestinal system rather than the skin.

B) Vomiting:
Vomiting is a common symptom of a complete small bowel obstruction. It occurs due to the blockage in the intestines, which prevents the passage of contents, leading to nausea and vomiting as the body tries to expel the obstruction.

C) Distended abdomen:
A distended abdomen is expected in cases of small bowel obstruction. The blockage causes a buildup of gas and fluids, leading to abdominal swelling and distention as the normal passage of intestinal contents is impeded.

D) Fluid overload:
Fluid overload is not a typical manifestation of a small bowel obstruction. Instead, dehydration and electrolyte imbalances are more likely due to vomiting and the inability to absorb fluids and nutrients properly.

E) Obstipation:
Obstipation, or severe constipation with an inability to pass stool or gas, is a key sign of a complete small bowel obstruction. The obstruction prevents the normal movement of intestinal contents, leading to a cessation of bowel movements.

A. "If you experience angina, take a 10-minute rest period, then resume exercise." B. "Stop exercising if your heart rate increases by 20 beats per minute from baseline." C. "Limit your exercise to an indoor facility to avoid exposure to the sun." D. "Begin by walking half a mile two times a day for the first week."

Correct Answer is D

Explanation

A) "If you experience angina, take a 10-minute rest period, then resume exercise."
It's important for clients to stop exercising immediately and consult a healthcare provider if they experience angina during exercise. Resting and then resuming exercise can be unsafe without medical advice, as angina indicates insufficient blood flow to the heart.

B) "Stop exercising if your heart rate increases by 20 beats per minute from baseline."
An increase in heart rate during exercise is expected, and stopping at a 20 BPM increase may be overly cautious. Clients should be taught to monitor for excessive fatigue or symptoms like dizziness, but a 20 BPM increase alone isn't necessarily a concern.

C) "Limit your exercise to an indoor facility to avoid exposure to the sun."
While excessive sun exposure can be a concern for some individuals, limiting exercise to indoors is unnecessary unless there are specific contraindications. Clients should be encouraged to exercise in environments they enjoy, with appropriate sun protection if outdoors.

D) "Begin by walking half a mile two times a day for the first week."
This recommendation is a reasonable starting point for postoperative exercise. Walking is a low-impact exercise that can help improve cardiovascular health gradually. Clients should gradually increase their activity level based on their tolerance and healthcare provider's advice.

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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

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