A client is admitted for an elective transurethral resection of the prostate (TURP). The client is receiving continuous bladder irrigation (CBI) after the procedure. In the post-anesthesia care unit (PACU), the nurse takes the client's vital signs and checks the urinary drainage bag frequently. Which assessment finding should the nurse prioritize reporting to the provider as an indication of a possible complication?
Blood pressure of 132/60 mmHg and heart rate of 90 beats per minute
Output to the Foley catheter has stopped
The patient reports a pain level of 5/10
Pink-colored urine in the Foley collection bag
The Correct Answer is B
A. This blood pressure and heart rate are within normal ranges for most patients. For example, a blood pressure of 132/60 mmHg is slightly elevated on the systolic side but not critically so, and a heart rate of 90 beats per minute is within the normal range (60-100 beats per minute).
B. Continuous bladder irrigation is used to prevent clots and debris from obstructing the urinary tract after a TURP. If the output from the Foley catheter has stopped, it may indicate a blockage or clot in the catheter or bladder, which can lead to bladder distension, discomfort, and potential kidney damage.
Immediate reporting to the provider is crucial because this could indicate a severe complication.
C. Pain levels are subjective, and a pain level of 5/10 indicates moderate discomfort. While pain management is important, a pain level of 5/10 is not unusual after TURP, and it can often be managed with appropriate pain relief measures.
D. Pink-colored urine is not uncommon immediately following a TURP as a result of bleeding or irritation from the procedure. This finding can be expected and may not indicate an immediate complication.
However, if the urine color changes to bright red or if there is a significant increase in blood, it could be more concerning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Pink, frothy sputum is typically associated with left-sided heart failure and pulmonary edema. This occurs when fluid backs up into the lungs due to left-sided heart failure. Since the question pertains to right-sided heart failure, this statement is not consistent with that condition.
B. Feeling short of breath when lying flat is known as orthopnea and is more commonly associated with left-sided heart failure. It occurs due to fluid shifting into the lungs when supine, which aggravates pulmonary congestion. This statement is not consistent with right-sided heart failure.
C. Hearing fluid in the lungs typically indicates left-sided heart failure, where fluid backs up into the pulmonary circulation, causing pulmonary edema. This symptom is associated with left-sided heart failure rather than right-sided heart failure.
D. Swelling of the legs, also known as peripheral edema, is a hallmark of right-sided heart failure. This occurs because the right side of the heart is unable to effectively pump blood out to the lungs, leading to fluid accumulation in the systemic venous circulation and resulting in swelling in the lower extremities and sometimes the abdomen
Correct Answer is D
Explanation
A. Guillain-Barre Syndrome is not a contagious disease. It is an autoimmune disorder that occurs when the immune system mistakenly attacks the peripheral nerves. GBS is not spread through respiratory droplets or any other form of infection transmission.
B. Guillain-Barre Syndrome causes demyelination in the peripheral nervous system, not the central nervous system. The central nervous system includes the brain and spinal cord, whereas the peripheral nervous system comprises the nerves outside the brain and spinal cord.
C. Guillain-Barre Syndrome is not a genetic disorder. It is considered an autoimmune condition that can be triggered by an infection or other environmental factors. While there may be genetic predispositions that affect susceptibility to autoimmune conditions, GBS itself is not classified as a genetic disorder.
D. Guillain-Barre Syndrome primarily affects the peripheral nervous system. It involves an immune- mediated attack on the peripheral nerves, leading to symptoms such as muscle weakness, tingling, and loss of reflexes.
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