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
Explanation
Choice A rationale: Intubation and mechanical ventilation may be needed if the respiratory muscles are affected by GBS, but this is not a routine intervention at this stage.
Choice B rationale: One of the main treatments of GBS is IV immunoglobulin therapy (IVIG), which involves infusing antibodies from donated blood plasma to block the harmful immune response that damages the nerves. Sandoglobulin is one of the brand names of IVIG used for GBS. IVIG can help shorten the duration and severity of the disease, and improve the recovery rate.
Choice C rationale: Methylprednisolone is a corticosteroid that can reduce inflammation, but it is not recommended for GBS, as it may worsen the condition or increase the risk of infection.
Choice D rationale: NG feeding tube may be required if the patient has difficulty swallowing, but this is also not a standard intervention at this time.
Correct Answer is A
Explanation
Choice A rationale: Arterial blood gas (ABG) findings provide direct information about oxygenation and acid-base balance in the blood, which can indicate hypoxemia and metabolic acidosis.
Choice B rationale: Oxygen saturation level provides information about oxygen saturation in the blood but doesn't give a complete assessment of acid-base balance or other gases in the blood.
Choice C rationale: White blood cell differential assesses different types of white blood cells and is not directly related to evaluating hypoxemia or metabolic acidosis.
Choice D rationale: Red blood cells (RBCs) and hemoglobin count findings are important but do not directly assess hypoxemia or metabolic acidosis.
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