A client has just undergone a prostatectomy for benign prostatic hyperplasia (BPH). Which of the following nursing interventions is most important in the immediate post-operative period?
Encourage deep breathing and coughing exercises to prevent atelectasis.
Maintain the client on strict bed rest for the first 48 hours after surgery,
Ensure that the client's indwelling catheter is patent and draining freely.
Monitor for signs of infection, such as fever and redness at the surgical site.
The Correct Answer is C
Rationale:
A. Deep breathing and coughing exercises are important but ensuring catheter patency is more critical immediately post-prostatectomy to prevent urinary retention and bladder distention.
B. Strict bed rest is generally not required; early ambulation is encouraged to reduce complications.
C. Maintaining a patent indwelling catheter is essential after prostatectomy to prevent urinary obstruction, bladder distension, and potential damage to the surgical site.
D. Monitoring for infection is important but is a routine ongoing assessment rather than the immediate priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Carbonated beverages can increase gastric pressure and promote reflux; they should be avoided.
B. Chocolate and coffee both relax the lower esophageal sphincter and can worsen GERD symptoms. Avoiding them demonstrates appropriate understanding of dietary recommendations.
C. Peppermint can also relax the lower esophageal sphincter and may worsen GERD symptoms, despite its soothing sensation.
D. Large meals increase stomach pressure and should be avoided; small, frequent meals are preferred for GERD management.
Correct Answer is B
Explanation
Rationale:
A. Purulent drainage is a sign of possible infection and requires prompt evaluation and intervention.
B. Clear, serous drainage is expected in the first 24 to 72 hours after pin placement and is not typically a cause for concern. It is a normal part of the healing process.
C. Pain combined with purulent drainage suggests infection, which is a serious complication of skeletal traction.
D. Inflammation and purulent drainage are both signs of possible infection at the pin site and warrant further investigation.
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