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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
A) Tachypnea:
Tachypnea, or rapid breathing, is not a typical symptom of acute pyelonephritis. This condition primarily affects the kidneys and urinary tract, and while it can cause systemic symptoms, tachypnea is more commonly associated with respiratory issues.
B) Nausea:
Nausea is a common symptom of acute pyelonephritis. The infection and inflammation of the kidneys can lead to gastrointestinal symptoms, including nausea and vomiting.
C) Hypothermia:
Hypothermia, or abnormally low body temperature, is not commonly associated with acute pyelonephritis. Patients with this condition are more likely to present with fever rather than hypothermia.
D) Bradycardia:
Bradycardia, or slow heart rate, is not typically seen in acute pyelonephritis. In fact, systemic infections and the associated fever can often lead to an increased heart rate (tachycardia).
E) Flank pain:
Flank pain is a hallmark symptom of acute pyelonephritis. The pain is usually located in the back and sides, near the affected kidney, and can be quite severe. This pain results from the inflammation and infection of the kidney.
Correct Answer is A
Explanation
A) Initiate frequent, short periods of exercise throughout the day: Frequent, short periods of exercise are beneficial for a client with left-sided hemiplegia. Regular movement helps maintain joint flexibility, muscle strength, and overall functional ability. This approach can prevent complications such as contractures and muscle atrophy.
B) Decrease the amount of range of motion performed if tightness occurs: If tightness occurs, rather than decreasing range of motion, it is important to address it through appropriate stretching and adjustments in exercise technique. Reducing range of motion could lead to further loss of mobility and function.
C) Perform range-of-motion exercises to the affected side once per day: Performing range-of-motion exercises only once per day is generally insufficient. To maintain or improve mobility and prevent contractures, range-of-motion exercises should be performed multiple times throughout the day, as directed by the care plan.
D) Avoid repetitive movements during exercise: Repetitive movements are not necessarily harmful and can be beneficial for improving motor function and muscle coordination. However, it is important to balance repetitive exercises with variety and adjust based on the client’s condition and tolerance.
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