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.
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 D
Explanation
A. While maintaining hydration is important, the priority is to address the continuous bright red bleeding from the urinary catheter by notifying the healthcare provider immediately.
B. Clamping the catheter may obstruct urine flow and worsen the situation. The nurse should not intervene without healthcare provider guidance.
C. Administering fresh frozen plasma may be necessary in some situations, but it is not the immediate action for addressing continuous bleeding from the urinary catheter.
D. This is the correct answer. Continuous bright red bleeding from the urinary catheter after TURP surgery may indicate bleeding complications that require immediate intervention and evaluation by the healthcare provider.
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