A common nursing diagnosis for a client in the immediate postoperative phase after transurethral resection of the prostate (TURP) is:

Ineffective peripheral tissue perfusion related to deep vein thrombosis

Acute pain related to pain of bladder spasms

Disturbed body image related the disfiguring surgery

Imbalanced nutrition, less than body requirements

Answer and Explanation

The Correct Answer is B

A. While monitoring for complications such as DVT is necessary, it is not the primary concern in the immediate postoperative phase.
B. Acute pain related to bladder spasms is a common postoperative issue for TURP patients due to the urinary catheter and bladder irrigation. Managing pain is a priority for patient comfort and recovery.
C. TURP does not typically lead to body image disturbances as it does not result in visible or disfiguring changes.
D. Imbalanced nutrition is not an immediate postoperative priority following TURP.

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Correct Answer is B

Explanation

A. Instructing the UAP to obtain a blood glucose level could be useful, but the nurse should prioritize assessing the client directly.
B. Assessing the client is the first step to confirm hypoglycemia and determine the severity, allowing for appropriate intervention.
C. Administering orange juice may be appropriate after confirming hypoglycemia, but an assessment should be performed first.
D. Administering dextrose is a severe intervention used when symptoms are extreme; assessment should occur first.

A. Give 15 grams of simple carbs at 3:00am B. Have a snack at bedtime. C. Increase the insulin dose. D. Do nothing, this is normal

Correct Answer is B

Explanation

A. Giving carbohydrates at 3:00 AM might prevent hypoglycemia temporarily but does not address the underlying issue.
B. Having a snack at bedtime helps prevent nighttime hypoglycemia, which can lead to rebound hyperglycemia, known as the Somogyi effect.
C. Increasing the insulin dose could exacerbate nocturnal hypoglycemia, worsening the Somogyi effect.
D. Doing nothing is inappropriate as the low 2:00 AM glucose level is a sign of the Somogyi effect.

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A common nursing diagnosis for a client in the immediate postoperative phase after transurethral resection of the prostate (TURP) is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client received ten (12) units of regular insulin at 08:00. At 11:30 the unlicensed assistant personnel (UAP) tells the nurse the client has a headache and is really acting funny. Which intervention should the registered nurse implement first?

Correct Answer is B

Explanation

The health care provider suspects the Somogyi effect in a 66-yr-old patient whose 2:00 AM blood glucose is 66 mg/dL. Which action will the nurse teach the patient to take?

Correct Answer is B

Explanation

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A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see?

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The nurse documents that the client has a problem of fluid volume excess (FVE). Which intervention should the nurse include in the plan of care? Select all that apply.

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