A client undergoing TURP surgery experiences bladder perforation during the procedure. What is the nurse's immediate action?
Inform the surgeon and anesthesia team about the complication.
Notify the client's family about the unexpected turn of events.
Document the incident in the client's medical record after the surgery.
Administer pain medication to the client to alleviate any discomfort.
The Correct Answer is A
A. This is the correct answer. Bladder perforation is a significant complication that requires immediate attention. The nurse should inform the surgical team to address the situation promptly.
B. Notifying the client's family about the complication is not the immediate action. The priority is to inform the surgical team and manage the situation.
C. While documentation is essential, it is not the immediate action required in this critical situation.
D. Administering pain medication may be necessary, but the priority is to address the bladder perforation and involve the surgical team to manage the complication.
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Related Questions
Correct Answer is D
Explanation
A. Maintaining strict fluid restrictions may not be necessary during TURP surgery and can lead to dehydration.
B. Preventing dehydration is essential, but the primary reason for fluid intake and output monitoring is to detect potential complications related to fluid overload or imbalance.
C. While proper irrigation of the surgical site is essential, fluid intake and output monitoring serve a broader purpose of assessing overall fluid balance and preventing complications.
D. This is the correct answer. Monitoring fluid intake and output during TURP surgery allows the nurse to assess for signs of fluid overload or imbalance, which can occur due to irrigation fluids and potential bleeding.
Correct Answer is C
Explanation
A. The prone position with the abdomen elevated is not the appropriate position for TURP surgery.
B. The supine position with the legs elevated is not the appropriate position for TURP surgery.
C. This is the correct answer. The lithotomy position with the feet in stirrups is the standard position for TURP surgery, as it provides access to the urinary tract for the procedure.
D. The lateral position with the affected side up is not the appropriate position for TURP surgery, as it does not provide the necessary access to the urinary tract.
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