Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

A) Occasional small clots in the urine:
Occasional small clots can be expected after a transurethral resection of the prostate (TURP) due to the surgical trauma to the prostate and surrounding tissues. However, any change in the nature or frequency of clots, or if they become larger, should be reported, but small clots are not immediately concerning in the early postoperative period.

B) Urine output of 300 mL over 8 hr:
This urine output is within a reasonable range. While urine output may be initially monitored closely after TURP, a volume of 300 mL over 8 hours does not constitute a concerning finding. It may be less than expected, but it is not an emergency. The nurse should continue to monitor urine output, but this is not immediately concerning unless the client has a significantly reduced or absent output.

C) Dark red urine:
Dark red urine is a concerning finding as it may indicate excessive bleeding or hemorrhage, especially within the first 24 hours after TURP. While some initial hematuria (blood in the urine) is common, the urine should not remain dark red or worsen. This could indicate active bleeding or a clot obstructing the urinary flow, which requires immediate intervention and reporting to the healthcare provider to prevent complications.

D) Frequent urge to urinate:
A frequent urge to urinate is not an unusual finding following TURP, as the bladder may be irritated due to the catheter or residual inflammation from the surgery. While it is a discomforting symptom, it is typically not an immediate concern and often resolves as the healing process progresses. However, persistent or painful urination may require further evaluation.

A) Irregular heart rate: An irregular heart rate is a key manifestation of hyperkalemia. Elevated potassium levels can interfere with the normal electrical activity of the heart, leading to arrhythmias, which can cause an irregular heart rate. In severe cases, hyperkalemia can lead to life-threatening cardiac events such as ventricular fibrillation or asystole.

B) Dry mucous membrane: Dry mucous membranes are more commonly associated with dehydration, not hyperkalemia. Dehydration can cause fluid volume depletion, which leads to dry mouth and other signs of insufficient hydration. While renal failure can lead to fluid balance issues, dry mucous membranes are not typically linked to elevated potassium levels.

C) Trousseau's sign: Trousseau's sign is a clinical indicator of hypocalcemia, not hyperkalemia. It is a spasm of the hand and wrist that occurs when a blood pressure cuff is inflated above systolic pressure for several minutes. This sign suggests low calcium levels, and while calcium imbalance can occur in renal failure, it is unrelated to hyperkalemia.

D) Hyperactive reflexes: Hyperactive reflexes are more commonly associated with conditions like hypocalcemia, rather than hyperkalemia. In hyperkalemia, the typical findings include muscle weakness or paralysis due to the effect of potassium on muscle and nerve function, but hyperactive reflexes would not be expected.