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 B

Explanation

Choice A reason:
Purulent drainage at the intravenous site access site would indicate a more severe infection, possibly grade 3 or 4 on the Infusion Nurses Society's phlebitis scale. This would be associated with more advanced symptoms such as pus formation, which is not characteristic of grade 1 phlebitis.

Choice B reason:
Redness at the intravenous access site with pain is indicative of grade 1 phlebitis according to the Infusion Nurses Society's phlebitis scale. This grade is characterized by erythema and possible pain at the site of the IV insertion, without more severe symptoms such as swelling or streak formation.

Choice C reason:
Red streaks on the affected extremity suggest a progression of the inflammatory response, potentially indicating a higher grade of phlebitis, such as grade 2 or 3. This symptom suggests that the inflammation is spreading along the vein, which is more serious than grade 1 phlebitis.

Choice D reason:
A palpable venous cord in the affected extremity would also suggest a more severe form of phlebitis, likely grade 3. This occurs when a thrombus forms along with inflammation of the vein, leading to a palpable cord-like structure.

A. Bradycardia B. Diarrhea C. Fatigue D. Hypertension

Correct Answer is C

Explanation

Choice A reason:
Bradycardia, or a heart rate that is slower than normal, is not a common finding in anemia. Anemia typically results in a compensatory increase in heart rate, known as tachycardia, to maintain adequate oxygen delivery to tissues.

Choice B reason:
Diarrhea is not a direct symptom of anemia. While it can be a postoperative complication due to various reasons, such as medication side effects or infections, it is not a symptom associated with anemia resulting from excess blood loss.

Choice C reason:
Fatigue is a hallmark symptom of anemia, regardless of the cause. When anemia is due to excess blood loss, the body's oxygen-carrying capacity is diminished due to the reduced number of red blood cells. This leads to fatigue, as tissues and organs receive less oxygen than is needed for optimal function.

Choice D reason:
Hypertension is not typically associated with anemia. In fact, anemia can sometimes lead to hypotension, or low blood pressure, because of the reduced volume of red blood cells in the circulatory system.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is assessing a client who is postoperative and has anemia due to excess blood loss following surgery. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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