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 B
Explanation
A. Gallstones are formed in the gallbladder and are not directly related to PKD.
B. Polycystic kidney disease (PKD) is a genetic disorder characterized by the growth of numerous cysts in the kidneys. These cysts can obstruct the flow of urine, making it easier for bacteria to grow and cause a urinary tract infection (UTI).
C. Hypotension is low blood pressure. While PKD can lead to kidney failure, which can cause hypotension, it is not a common complication.
D. Osteoporosis is a condition characterized by weak bones. While PKD can lead to kidney failure, which can affect calcium metabolism and contribute to osteoporosis, it is not a common complication.
Correct Answer is B
Explanation
A. The immediate concern with abrupt cessation is more related to adrenal insufficiency rather than hyperglycemia. However, chronic use of prednisone can contribute to glucose intolerance and diabetes, but this is not the primary issue with sudden discontinuation.
B. Abrupt discontinuation of prednisone can lead to adrenal insufficiency because the body has become reliant on the medication to suppress inflammation and regulate various bodily functions. The adrenal glands may not immediately resume normal cortisol production, which can lead to symptoms of adrenal insufficiency, including hypotension.
C. Fluid retention is a common side effect of prednisone use. However, stopping prednisone suddenly does not typically cause fluid retention; rather, it can lead to other issues like adrenal insufficiency. Fluid retention is more related to the medication's use rather than its abrupt discontinuation.
D. Abruptly stopping high-dose prednisone, especially after long-term use, can be dangerous. The body may not immediately resume normal cortisol production, leading to symptoms of adrenal insufficiency, such as fatigue, weakness, and hypotension. It is crucial to taper off prednisone gradually under medical supervision to allow the adrenal glands time to recover and to avoid withdrawal symptoms.
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