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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A reason:
Cold extremities are not a typical symptom associated with Paget's disease of the bone. This condition usually does not affect the temperature of the limbs directly.
Choice B reason:
Skeletal pain is a common symptom in Paget's disease due to the abnormal bone remodeling process. The affected bones may become painful, especially in the pelvis, spine, skull, and long bones.
Choice C reason:
Visual loss can occur if Paget's disease affects the skull, leading to increased pressure on the nerves associated with vision. This pressure can result in visual impairment or loss.
Choice D reason:
Cranial enlargement is a possible finding in Paget's disease when the skull is involved. The abnormal bone growth can cause the skull to increase in size.
Choice E reason:
An abnormal gait may develop if Paget's disease affects the legs, causing the bones to bow and leading to difficulty walking.
Correct Answer is C
Explanation
Choice A reason:
Hypertension is not typically an early manifestation of fat embolism syndrome (FES). FES is more commonly associated with hypoxemia, which can lead to hypotension rather than hypertension².
Choice B reason:
While a swollen calf may indicate deep vein thrombosis, it is not an early sign of FES. FES primarily affects the lungs and neurological systems early on, rather than causing localized swelling such as in a calf².
Choice C reason:
Tachypnea, or rapid breathing, is indeed an early sign of FES. This symptom usually develops before others and is due to the fat globules causing respiratory distress by blocking the pulmonary microcirculation²³⁴.
Choice D reason:
Bradycardia, or a slower than normal heart rate, is not an early sign of FES. Instead, patients may experience tachycardia as a response to hypoxemia and respiratory distress².
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