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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is the correct answer. Informing the healthcare provider about the client's anticoagulant medication is crucial before surgery, as it can affect the surgical plan and potential bleeding risks during TURP.
B. Withholding all medications, including anticoagulants, should only be done under the direction of the healthcare provider and anesthesia team. Abruptly stopping anticoagulants can lead to significant medical risks.
C. Continuing the anticoagulant as prescribed may pose a bleeding risk during surgery, so it is essential to involve the healthcare provider in the decision.
D. Administering a blood-thinning agent to counteract the anticoagulant effects is not appropriate and can lead to complications. The healthcare provider should decide on the management of anticoagulation therapy before surgery.
Correct Answer is B
Explanation
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.
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