A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following actions should the nurse take?

Irrigate the catheter with sterile water

Clamp the drainage catheter during ambulation

Report viscous drainage with clots to the provider

Remove the catheter if the client feels a strong urge to urinate

Answer and Explanation

The Correct Answer is C

Choice A reason: Irrigating the catheter with sterile water is an incorrect action, because the catheter should be irrigated with sterile normal saline (0.9% sodium chloride) to prevent hemolysis of the red blood cells.

Choice B reason: Clamping the drainage catheter during ambulation is an incorrect action, because the catheter should be kept patent and unclamped at all times to prevent obstruction and infection.

Choice C reason: Reporting viscous drainage with clots to the provider is a correct action, because it indicates that the irrigation is not effective and the client may need manual irrigation or surgical intervention.

Choice D reason: Removing the catheter if the client feels a strong urge to urinate is an incorrect action, because the catheter should be left in place until the provider orders its removal. The client may feel a sensation of bladder fullness or spasms due to the irrigation fluid, which can be relieved by medication or adjustment of the flow rate.

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Correct Answer is B

Explanation

Choice A reason: This is an incorrect action, because elevating the residual limb on a soft pillow can cause contractures and impair the blood flow to the stump. The residual limb should be elevated only for the first 24 hr after surgery, and then positioned flat on the bed.

Choice B reason: This is the correct action, because assisting the client to a prone position every 4 hr can prevent hip flexion contractures and promote the range of motion of the hip joint. The client should lie prone for 20 to 30 minutes at a time, with the residual limb extended.

Choice C reason: This is an incorrect action, because reapplying a bandage to the residual limb every 12 hr can increase the risk of infection and delay the healing of the wound. The bandage should be changed only when it is soiled or loose, and under sterile technique.

Choice D reason: This is an incorrect action, because applying dressings to the site in a proximal-to-distal direction can cause edema and impair the circulation to

A. “Because most of my colon is still intact and functioning, my stool will be formed.” B. “My stoma will appear large at first, but it will shrink over time.” C. “My colostomy will begin to function 2 to 6 days after surgery.” D. “My diet will have to change to a soft diet after surgery.”

Correct Answer is D

Explanation

Choice A reason: This is a correct statement, because the stool consistency depends on the location of the colostomy. A sigmoid colostomy is located in the lower part of the colon, where most of the water is absorbed, so the stool will be formed.

Choice B reason: This is a correct statement, because the stoma size will decrease as the swelling subsides and the wound heals. The stoma will reach its final size in about 6 to 8 weeks after surgery.

Choice C reason: This is a correct statement, because the colostomy function will resume gradually after surgery, depending on the bowel motility and the presence of gas or stool. The colostomy will usually start to function 2 to 6 days after surgery.

Choice D reason: This is an incorrect statement, because the diet does not have to change to a soft diet after surgery. The client can resume a normal diet as tolerated, unless there are specific dietary restrictions or recommendations from the provider. A soft diet may be recommended only for the first few days after surgery, to avoid bowel obstruction or irritation.

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A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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