A client has undergone a transurethral resection of the prostate (TURP) for benign prostatic hypertrophy (BPH). He is currently being treated with continuous bladder irrigation (CBI) and is complaining of an increase in the severity of bladder spasms. Which intervention should the nurse perform first?

Perform a bladder scan.

Stop the irrigation and note findings in the chart.

Administer an oral analgesic.

Ensure that the catheter is draining properly.

Answer and Explanation

The Correct Answer is D

Choice A Reason
Performing a bladder scan can help determine the volume of urine in the bladder and assess for urinary retention, which could contribute to bladder spasms. However, this is not typically the first intervention. The priority is to ensure that the catheter is patent and draining correctly, as blockages can cause immediate discomfort and increased spasms

Choice B Reason
Stopping the irrigation could be considered if there is a concern that the CBI is contributing to the spasms. However, this would not be the first action taken. It is essential first to assess the catheter's patency and the flow of the irrigation to rule out any obstruction or kinking causing the spasms.

Choice C Reason
Administering an oral analgesic may help alleviate the discomfort caused by bladder spasms, but it does not address the underlying cause. Pain relief is important, but the initial step should be to check for and resolve any mechanical issues with the catheter system that could be causing the spasms.

Choice D Reason
Ensuring that the catheter is draining properly is the first and most crucial intervention. If the catheter is blocked or kinked, it can cause bladder distention and increased spasms. Checking the catheter's patency and the flow of irrigation can quickly resolve the issue and provide relief to the patient. If the catheter is found to be obstructed, resolving the blockage can decrease the severity of the spasms and improve the patient's comfort.

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Free Nursing Study Resources

Correct Answer is ["A","B","C"]

Explanation

Choice A reason:
Packaged meats, including salami and bacon, are typically high in sodium, which can contribute to increased blood pressure. The American Heart Association recommends that individuals with hypertension limit their sodium intake to no more than 2,300 milligrams per day, with an ideal limit of no more than 1,500 milligrams for most adults². Since packaged meats are often cured with salt, they can significantly contribute to the daily sodium intake, potentially exacerbating hypertension.

Choice B reason:
Grapefruit juice can interact with certain antihypertensive medications, potentially leading to higher levels of the medication in the bloodstream and an increased risk of side effects¹. This interaction occurs because grapefruit juice can inhibit the action of an enzyme that metabolizes medication, leading to an unintended increase in medication levels.

Choice C reason:
Canned soups are often high in sodium, which can contribute to increased blood pressure. Even low-sodium varieties can still contain significant amounts of sodium. It's important for individuals with hypertension to read labels carefully and choose options with the lowest sodium content possible².

Choice D reason:
Fresh fruits are generally recommended for individuals with hypertension. They are rich in potassium, which can help lower blood pressure by balancing out the negative effects of sodium and easing tension in the blood vessel walls¹. Fresh fruits should not be avoided unless there is a specific reason related to another health condition or medication interaction.

Choice E reason:
Fresh shellfish, like fresh fruits, are typically safe for individuals with hypertension to consume. They provide essential nutrients without the added sodium that is found in processed foods. However, it's important to consume them in moderation and to prepare them without adding excessive salt or high-sodium sauces.

A. Creatinine level is 0.8 mg/dL. B. Potassium level is 4.2 mEq/L. C. White blood cell count is 9,000 mm³. D. Hemoglobin is 7.1 g/dL.

Correct Answer is D

Explanation

Choice A Reason
A creatinine level of 0.8 mg/dL falls within the normal range for adults, which is typically 0.6 to 1.2 mg/dL for males and 0.5 to 1.1 mg/dL for females. This indicates normal kidney function and is not a cause for immediate intervention post-operatively.

Choice B Reason
A potassium level of 4.2 mEq/L is within the normal range, which is generally between 3.6 and 5.2 mEq/L. This level indicates a stable electrolyte balance and is not a cause for immediate concern following shoulder replacement surgery.

Choice C Reason
A white blood cell (WBC) count of 9,000 mm³ is within the normal range, which typically spans from 4,500 to 11,000 WBCs per mm³. This suggests there is no active infection or inflammation that requires immediate intervention.

Choice D Reason
A hemoglobin level of 7.1 g/dL is considered low, as the normal range for adult males is generally 13.8 to 17.2 g/dL and for adult females is 12.1 to 15.1 g/dL. Low hemoglobin can indicate anemia, which may be due to blood loss during surgery or other underlying conditions. This requires immediate intervention to address potential oxygenation issues and determine the cause of the anemia.

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Naxlex Comprehensive Predictor Exams

The nurse is providing discharge teaching to a client newly diagnosed with hypertension. Which food item(s) should the nurse instruct the client to avoid in order to assist In controlling the blood pressure? (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","C"]

Explanation

Which data is cause for immediate intervention for a client after a right shoulder replacement?

Correct Answer is D

Explanation

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