A client undergoing TURP surgery develops a sudden onset of tachycardia, hypotension, and confusion. What is the nurse's priority action?
Administer pain medication to address any discomfort.
Inform the surgeon and anesthesia team immediately.
Reassure the client that these symptoms are expected.
Initiate a rapid infusion of intravenous fluids.
The Correct Answer is B
A. Administering pain medication may not be appropriate for these symptoms, as the client's condition requires immediate attention and assessment.
B. This is the correct answer. The sudden onset of tachycardia, hypotension, and confusion indicates a potential complication or adverse reaction that requires immediate intervention from the surgical and anesthesia teams.
C. Reassuring the client is important, but it is not the priority when the client is experiencing concerning symptoms.
D. Initiating a rapid infusion of intravenous fluids may not be appropriate without a proper assessment and evaluation of the client's condition. The priority is to inform the surgical and anesthesia teams to address the situation promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Assessing pain level and administering pain medication is important, but the priority during the immediate postoperative period is to monitor vital signs and assess for signs of hemorrhage or other complications.
B. This is the correct answer. Monitoring vital signs and assessing for signs of hemorrhage, such as continuous bright red bleeding, tachycardia, and hypotension, is essential to detect and address any complications promptly.
C. Evaluating the client's urinary output and catheter patency is important but may not be the immediate priority if there are concerns about hemorrhage or other complications.
D. Assessing the client's surgical incision for signs of infection is essential, but it may not be the immediate priority during the immediate postoperative period. The focus should be on assessing vital signs and for signs of bleeding or other complications.
Questions
Correct Answer is B
Explanation
A. While erectile dysfunction can occur after TURP surgery, it is not accurate to describe it as a "common" complication. The actual incidence varies among individuals.
B. This is the correct answer. Erectile dysfunction is a possible complication after TURP surgery due to the proximity of nerves involved in erectile function. However, it is often temporary and resolves within a few months as the body heals.
C. TURP surgery can have an impact on erectile function due to its proximity to the nerves and structures involved in sexual function.
D. It is not appropriate for the nurse to dismiss the client's concerns. Erectile dysfunction is a valid concern for many clients undergoing TURP surgery.
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