A nurse is assessing a client who is 2 days postoperative following a transurethral resection of the prostate and has an indwelling urinary catheter in place. Which of the following findings should the nurse expect?

Small clots with tissue in the urine

Dark red urine

Urinary output 25 mL/hr

Pain of 8 on a scale of 0 to 10

Answer and Explanation

The Correct Answer is A

A. Small clots with tissue in the urine. It is expected for a client 2 days post-TURP to have small clots and tissue debris in the urine as part of the healing process. Continuous bladder irrigation (CBI) often helps clear these.

B. Dark red urine. Bright red or dark red urine can indicate active bleeding, which is not expected 2 days post-op and requires immediate intervention.

C. Urinary output 25 mL/hr. This is too low (normal output should be at least 30 mL/hr) and could indicate catheter blockage, dehydration, or renal impairment, which is not expected.

D. Pain of 8 on a scale of 0 to 10. Mild discomfort is expected, but severe pain (8/10) is abnormal and could indicate bladder spasms, catheter blockage, or another complication requiring intervention.

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Correct Answer is ["B","D"]

Explanation

A. Blood pressure: The client’s BP is 128/84 mm Hg, which is within the normal range. Although the client has chronic hypertension, this BP reading does not indicate an immediate concern.

B. Fetal heart rate: The fetal heart rate (FHR) is 165/min, which is tachycardia (normal FHR range is 110–160/min). Fetal tachycardia can indicate infection, maternal fever, fetal distress, or hypoxia and requires immediate follow-up.

C. Fetal station: The station is 0, which means the presenting part is at the level of the ischial spines. This is normal for a laboring client at 4 cm dilation and does not require immediate intervention.

D. Characteristics of amniotic fluid: The fluid is green, indicating the presence of meconium-stained amniotic fluid, which suggests fetal distress or hypoxia. This requires immediate follow-up, as the baby is at risk for meconium aspiration syndrome.

E. Duration of contraction: The contraction lasted 40 seconds, which is within the normal range (30–90 seconds). This is not an immediate concern.

A. Bradycardia B. Edema C. Hypotension D. Crackles

Correct Answer is C

Explanation

A. Bradycardia is not expected with dehydration. Instead, tachycardia occurs as a compensatory response to low blood volume.
B. Edema is not a symptom of dehydration. Instead, dehydration leads to decreased tissue perfusion and dry mucous membranes.
C. Hypotension occurs due to decreased blood volume from fluid loss, leading to low blood pressure and potential dizziness or weakness.
D. Crackles are not expected in dehydration. Instead, lung sounds are typically clear unless another condition is present.

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A nurse is assessing a client who is 2 days postoperative following a transurethral resection of the prostate and has an indwelling urinary catheter in place. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

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