The nurse cares for a client six hours post-operative following a transurethral resection of a prostate (TURP).
The client is demonstrating signs and symptoms of ?
urinary catheter obstruction
shock
hyponatremia
urinary tract infection
The Correct Answer is A
Choice A rationale: The signs and symptoms of urinary catheter obstruction include hematuria with clots, bladder spasms, and a feeling of urinary urgency. The nurse should increase the rate of the continuous bladder irrigation to flush out the clots and relieve the obstruction. The nurse should also monitor the client's vital signs, fluid balance, and pain level. The other options are not consistent with the client's presentation.
Choice B rationale: Shock would cause hypotension, tachycardia, and decreased urine output.
Choice C rationale: Hyponatremia would cause confusion, weakness, and seizures.
Choice D rationale: Urinary tract infection would cause fever, chills, and foul-smelling urine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale: This is a normal value, indicating normal renal function. The client does not have any signs of kidney damage or impairment.
Choice B rationale: This is an elevated value, indicating an infection or inflammation in the body. Acute appendicitis is a common cause of increased white blood cells, as the appendix becomes inflamed and infected. This finding requires immediate follow-up to monitor the client's condition and prevent complications such as perforation or peritonitis.
Choice C rationale: This is a high value, indicating impaired renal function or dehydration. The client may have decreased urine output due to vomiting and fluid loss, or may have underlying kidney problems. This finding requires immediate follow-up to assess the client's hydration status and renal function, and to provide appropriate fluid and electrolyte replacement.
Choice D rationale: This is a sign of peritoneal irritation, which may indicate that the appendix has ruptured or is close to rupturing. This is a medical emergency that requires immediate surgical intervention to remove the appendix and prevent sepsis and shock.
Choice E rationale: This is a low value, indicating hypokalemia or low potassium levels in the blood. The client may have lost potassium due to vomiting and fluid loss, or may have underlying electrolyte imbalances. This finding requires immediate follow-up to assess the client's cardiac function and muscle strength, and to provide appropriate potassium supplementation.
Choice F rationale: These are common symptoms of acute appendicitis, as the inflammation and infection of the appendix cause irritation of the gastrointestinal tract. These symptoms do not require immediate follow-up, but they should be managed with antiemetics and fluids to prevent dehydration and electrolyte imbalances.
Correct Answer is C
Explanation
Choice A rationale: Irregular respirations, bradycardia, and widened pulse pressure might indicate increased intracranial pressure.
Choice B rationale: This set of symptoms is often seen in cardiac tamponade and is referred to as the Beck’s triad and not Cushing's triad.
Choice C rationale: Cushing's triad is a set of clinical signs associated with increased intracranial pressure (ICP) and typically includes bradycardia (slow heart rate),
hypertension (elevated blood pressure), and irregular breathing patterns. Fixed pupils can also be present in some cases, but it's important to note that this triad is not always consistently present and may vary from person to person.
Choice D rationale: This set of symptoms describes symptoms of shock, not specifically Cushing's triad.
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