A nurse is caring for a client who is 2 hours postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view as an indication of a postoperative complication?

Oral temperature of 38.2°C (100.76°F)

Output of burgundy-colored urine

Pulse rate of 88/min

An urge to void despite having an indwelling urinary catheter

Answer and Explanation

The Correct Answer is A

Choice A reason: An elevated oral temperature of 38.2°C (100.76°F) postoperatively can indicate an infection, which is a common complication after surgical procedures. In the context of TURP, a fever could suggest a urinary tract infection or sepsis, especially if accompanied by other symptoms such as chills or an elevated white blood cell count.

Choice B reason: The output of burgundy-colored urine can be expected in the immediate postoperative period following a TURP due to bleeding. However, it should gradually lighten in color. Persistent or worsening hematuria could indicate a complication, but it is not uncommon to see some blood in the urine shortly after the procedure

Choice C reason: A pulse rate of 88/min is within the normal range (60-100 beats per minute) and is not typically indicative of a postoperative complication. It is important to consider the patient's baseline heart rate and any other symptoms they may be experiencing.

Choice D reason: Feeling an urge to void despite having an indwelling urinary catheter can occur due to bladder spasms or irritation from the catheter itself. While uncomfortable, this sensation is not uncommon after TURP and does not necessarily indicate a complication.

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Correct Answer is A

Explanation

Choice A reason:
Morphine is an opioid analgesic that can cause a decrease in gastrointestinal motility, leading to constipation and exacerbation of paralytic ileus, a condition where there is a cessation of peristalsis in the intestine. In the case of paralytic ileus, the intestinal contents cannot move, which can lead to bowel distention, pain, and further complications. Therefore, morphine is contraindicated in clients with paralytic ileus due to the risk of worsening the condition..

Choice B reason:
While morphine can suppress cough and provide some relief in respiratory conditions, it is not contraindicated in bronchitis pleurisy unless respiratory depression is present. However, caution is advised as morphine can cause respiratory depression and should be used carefully in patients with underlying respiratory disorders.

Choice C reason:
Morphine is often used in the management of acute myocardial infarction (MI) to relieve chest pain, reduce anxiety, and decrease the workload on the heart by lowering blood pressure and heart rate. It is not contraindicated in MI; in fact, it can be beneficial in managing the symptoms associated with MI.

Choice D reason:
Postoperative pain management following hip arthroplasty often includes opioids like morphine. Morphine is not contraindicated in this situation and can be used to control postoperative pain, provided that the patient's respiratory function is closely monitored

A. Antinuclear antibody (ANA) B. Erythrocyte sedimentation rate (ESR) C. Rheumatoid factor (RF) D. White blood cell (WBC) count

Correct Answer is B

Explanation

Choice A reason:
Antinuclear antibody (ANA) is a test used to help diagnose autoimmune disorders, including RA. However, ANA is not typically used to monitor the effectiveness of treatment with aspirin in RA. Aspirin is an anti-inflammatory medication, and its effectiveness would not be directly measured by changes in ANA levels.

Choice B reason:
Erythrocyte sedimentation rate (ESR) is a blood test that can detect inflammation in the body and is commonly used to assess the severity of inflammation in patients with RA. Aspirin can reduce inflammation, so a decrease in ESR can indicate the effectiveness of aspirin therapy in managing RA symptoms.

Choice C reason:
Rheumatoid factor (RF) is an antibody that can be present in the blood of people with RA. While RF can be used to help diagnose RA, it is not typically used to monitor the effectiveness of aspirin therapy. RF levels can remain elevated even when symptoms are well-controlled.

Choice D reason:
White blood cell (WBC) count is a measure of the body's immune response and can be elevated in cases of infection or inflammation. However, WBC count is not specifically used to monitor the effectiveness of aspirin therapy in RA. Aspirin's primary effect is on reducing inflammation and pain, not necessarily on altering WBC counts.

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A nurse is caring for a client who is 2 hours postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view as an indication of a postoperative complication?

Nursing Test Bank

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