A client develops signs of fluid overload, such as dyspnea, crackles in the lungs, and peripheral edema, after TURP surgery. What is the nurse's priority intervention?
Administering diuretics to promote urine output and fluid elimination.
Elevating the head of the bed and providing oxygen therapy as needed.
Encouraging the client to limit fluid intake to prevent further overload.
Restricting sodium intake in the client's diet.
The Correct Answer is B
A. Administering diuretics may be necessary, but the priority is to improve respiratory distress and oxygenation by elevating the head of the bed and providing oxygen therapy.
B. This is the correct answer. The priority intervention for signs of fluid overload is to improve respiratory function and oxygenation by elevating the head of the bed and providing oxygen therapy as needed.
C. Encouraging the client to limit fluid intake is not the priority when the client is experiencing signs of fluid overload. The focus should be on improving respiratory function.
D. Restricting sodium intake may be appropriate in some cases, but the priority is to address the respiratory distress associated with fluid overload.
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Related Questions
Correct Answer is C
Explanation
A. Encouraging the client to delay voiding may lead to urinary retention and increase the risk of complications. This is not an appropriate intervention for urinary urgency and frequency after TURP surgery.
B. Limiting fluid intake may lead to dehydration and affect the overall health of the client. Adequate fluid intake is important for proper healing and preventing complications after TURP surgery.
C. This is the correct answer. Anticholinergic medications can help reduce urinary urgency and frequency by relaxing the bladder muscles and reducing bladder spasms.
D. Kegel exercises are helpful for strengthening the pelvic floor muscles but may not be the best intervention for addressing urinary urgency and frequency after TURP surgery. Anticholinergic medications are more appropriate in this case.
Correct Answer is C
Explanation
A. The prone position with the abdomen elevated is not the appropriate position for TURP surgery.
B. The supine position with the legs elevated is not the appropriate position for TURP surgery.
C. This is the correct answer. The lithotomy position with the feet in stirrups is the standard position for TURP surgery, as it provides access to the urinary tract for the procedure.
D. The lateral position with the affected side up is not the appropriate position for TURP surgery, as it does not provide the necessary access to the urinary tract.
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