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?

The correct answer is: a, b, c, and e.

Choice A: “I will make sure to feel for changes in my underarm area.”

Reason: This statement is correct because the underarm area (axilla) contains lymph nodes that can be affected by breast cancer. Including the underarm area in a breast self-exam helps in detecting any unusual lumps or changes that could indicate a problem.

Choice B: “It is important to press firmly when feeling my breasts to detect changes.”

Reason: This statement is correct because using firm pressure during a breast self-exam helps to feel the deeper tissues of the breast, which is essential for detecting any abnormalities or lumps that might be present.

Choice C: “I don’t have to lie down to check my breasts. I can stand in the shower.”

Reason: This statement is correct because performing a breast self-exam in the shower is a common and effective method. The wet and slippery skin makes it easier to feel for any changes or lumps in the breast tissue.

Choice D: “If I feel a firm ridge in the lower curve of my breasts, I should report this immediately.”

Reason: This statement is incorrect because it is normal to feel a firm ridge in the lower curve of the breast. This ridge is part of the normal breast anatomy and does not necessarily indicate a problem.

Choice E: “Since I no longer have periods, I can perform an examination at any time of the month.”

Reason: This statement is correct because menopausal women do not have menstrual cycles to guide the timing of their breast self-exams. Therefore, they can choose any consistent day each month to perform the exam.

Choice A reason:
Activities that could result in bleeding should be minimized for a client with neutropenia due to the increased risk of infection from open wounds. However, this is not the primary restriction related to neutropenia itself but rather a general precaution for patients with low platelet counts or other clotting issues.

Choice B reason:
Restricting all visitors from entering the client's room is not necessary unless the visitors are sick or have been exposed to infectious diseases. Neutropenic patients are at increased risk for infection, so visitors should be screened for illness, but complete isolation is not required.

Choice C reason:
Modifying oral fluid intake to between meals only is not a standard restriction for neutropenic patients. Adequate hydration is essential, and there are no specific neutropenia-related reasons to restrict fluids to between meals.

Choice D reason:
Fresh flowers and potted plants should be avoided in the room of a neutropenic patient. They can harbor fungi and other microorganisms that could cause infection in an immunocompromised individual. Neutropenic precautions typically include avoiding standing water and plants that may contain harmful bacteria or fungi.