A client who underwent a TURP reports severe lower abdominal pain and difficulty urinating. The nurse observes blood clots in the client's urine bag. What action should the nurse take first?
Administer a pain reliever as ordered by the healthcare provider.
Notify the healthcare provider immediately about the client's symptoms.
Encourage the client to drink more fluids to dilute the urine.
Instruct the client to perform deep breathing exercises to manage pain.
The Correct Answer is B
A. Administering pain relief may be necessary, but the nurse's first action should be to notify the healthcare provider about the client's severe pain and other concerning symptoms.
B. This is the correct answer. Severe lower abdominal pain, difficulty urinating, and the presence of blood clots in the urine may indicate postoperative complications after TURP. The nurse should notify the healthcare provider immediately for further evaluation and intervention.
C. Encouraging the client to drink more fluids may be helpful, but it is not the first action when the client experiences severe pain and other concerning symptoms.
D. Deep breathing exercises can help manage pain, but the nurse should first address the client's acute symptoms and notify the healthcare provider for appropriate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) This response is not accurate. TURP is primarily performed for benign prostatic hyperplasia (BPH) or prostate enlargement and not for prostate cancer removal.
B) This is the correct answer. TURP is a surgical procedure that involves removing a portion of the prostate gland to alleviate urinary symptoms caused by BPH, such as urinary frequency, urgency, and difficulty in urination.
C) This statement is not accurate. TURP is a therapeutic procedure, not a diagnostic one.
D) This response is incorrect. TURP is a surgical procedure and does not involve catheter insertion for drainage.
Correct Answer is B
Explanation
A. Educating the client about postoperative care instructions is essential, but it is not the primary responsibility related to informed consent.
B. This is the correct answer. The nurse's primary responsibility is to ensure that the client is adequately informed about the risks, benefits, and alternatives to the surgery and that they provide voluntary and informed consent. The nurse witnesses the client's signature on the consent form to verify that the client understands and agrees to the procedure.
C. Explaining the surgical procedure is part of the informed consent process, but witnessing the client's signature is the primary responsibility related to informed consent.
D. Ensuring the client is medically fit for the surgery is crucial, but it is not the primary responsibility related to informed consent.
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