A client arrives at the medical-surgical unit 4 hours after a transurethral resection of the prostate. A triple-lumen catheter for continuous bladder irrigation with normal saline is infusing and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag.

Which action should the nurse take?

Decrease the flow rate.

Irrigate the catheter manually.

Discontinue infusing solution.

Monitor catheter drainage.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Decreasing the flow rate of the irrigation solution is not the best action in this situation. The presence of blood clots in the tubing and collection bag indicates that the client may be experiencing clot retention, which can lead to urinary obstruction. Decreasing the flow rate may not provide sufficient force to dislodge clots from the catheter, which could exacerbate the problem.
Choice B rationale
Manually irrigating the catheter is the most appropriate action when blood clots are observed in the tubing and collection bag. Clots can obstruct the catheter and disrupt the continuous bladder irrigation, leading to urinary retention and increased discomfort for the client. Manual irrigation can help dislodge and remove these clots, ensuring the patency of the catheter and the effectiveness of the irrigation.
Choice C rationale
Discontinuing the infusion of the irrigation solution is not the best action in this situation. The purpose of continuous bladder irrigation after a transurethral resection of the prostate is to prevent clot formation and retention by continuously flushing the bladder. Discontinuing the infusion could lead to the formation of more clots, potentially causing urinary obstruction.
Choice D rationale
While monitoring catheter drainage is an important part of postoperative care, it is not the most appropriate action in this situation. The presence of blood clots in the tubing and collection bag indicates a potential problem that requires immediate intervention. Simply monitoring the situation without taking action to resolve it could lead to urinary obstruction and increased discomfort for the client.

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Correct Answer is C

Explanation

Choice A rationale
While the activity level of bowel sounds can provide information about the functioning of the gastrointestinal system, it is not the most important data to manage the patient’s pain from chronic pancreatitis.
Choice B rationale
The level and amount of physical activity can affect the patient’s pain level, but it is not the most crucial data for managing pain in chronic pancreatitis.
Choice C rationale
Eating patterns of dietary intake are the most important data to manage the patient’s pain. In chronic pancreatitis, certain foods can exacerbate the pain. Understanding the patient’s dietary habits can help in providing appropriate dietary modifications.
Choice D rationale
The color and consistency of feces can provide information about the patient’s digestive health, but it is not the most important data to manage the patient’s pain from chronic pancreatitis.

A. Decreased renin-angiotensin response related to an increase in renal blood flow. B. Hypoalbuminemia that results in a decreased colloidal oncotic pressure. C. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules. D. Decreased portacaval pressure with greater collateral circulation.

Correct Answer is B

Explanation

Choice A rationale
While the renin-angiotensin response can be affected in cirrhosis, it is not the primary mechanism contributing to edema and ascites. In cirrhosis, there can be a decrease in renal blood flow which can lead to activation of the renin-angiotensin system, but this is not the main cause of fluid accumulation.
Choice B rationale
Hypoalbuminemia, or low levels of albumin in the blood, is a common occurrence in cirrhosis. Albumin is a protein that helps maintain oncotic pressure, which keeps fluid in the blood vessels. When albumin levels are low, fluid can leak out of the blood vessels and accumulate in the abdomen (ascites) and in the tissues, causing edema.
Choice C rationale
Hyperaldosteronism can occur in cirrhosis and can contribute to fluid retention. However, it is not the primary mechanism leading to edema and ascites. Aldosterone promotes sodium and water reabsorption in the kidneys, which can contribute to fluid retention, but this is usually a secondary response to other changes in the body.
Choice D rationale
Decreased portacaval pressure with greater collateral circulation is not the primary mechanism contributing to edema and ascites in cirrhosis. While portal hypertension is a common complication of cirrhosis, it is not directly responsible for the development of edema and ascites.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with chronic pancreatitis who reports persistent gnawing abdominal pain. What assessment data is most important for the nurse to obtain to help manage the patient’s pain?

Correct Answer is C

Explanation

The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?

Correct Answer is B

Explanation

After a transurethral resection of the prostate (TURP), a patient is discharged from the hospital with an indwelling urinary catheter. What is the most important instruction for the nurse to include in the discharge teaching plan?

The nurse is caring for a patient with a burn that is severely swollen, and the wound bed appears brown and yellow. The patient reports no pain. How should the nurse classify the depth of this burn?

A client who was recently diagnosed with Raynaud’s disease is concerned about pain management. Which nursing instruction should the nurse provide?

While providing care for a patient with Guillain-Barre syndrome, the nurse conducts a neurological assessment every four hours. Which finding from the assessment requires immediate intervention by the nurse?

An hour after administering 60 mg of furosemide intravenously (IV), which assessments should the nurse perform to determine the patient’s response to treatment? (Select all that apply.)

A patient with gouty arthritis is experiencing tenderness and swelling in the right ankle and big toe. The nurse notes that the inflammation extends above the ankle area. The patient has been prescribed colchicine and indomethacin. What should the nurse include in the discharge teaching?

A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client’s plan of care?