A nurse is caring for a client who is 2 hr postoperative following a transurethral resection of the prostate (TURP) gland.

Which of the following assessments should the nurse view to be an indication of a postoperative complication?

Output of burgundy-colored urine.

Oral temperature of 38.2° C (100.76° F).

An urge to void despite having an indwelling urinary catheter.

Pulse rate of 88/min.

Answer and Explanation

The Correct Answer is A

Choice A rationale:
Output of burgundy colored urine can indicate bleeding, which is a complication after TURP.
Choice B rationale:
A slight fever might be normal postoperatively. However, a high fever could indicate an infection.
Choice C rationale:
An urge to void despite having an indwelling urinary catheter can be a normal sensation following surgery.
Choice D rationale:
A pulse rate of 88/min is within the normal range (60-100/min).

Nursing Test Bank

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Correct Answer is B

Explanation

Choice A rationale:
Alteration in body image is a concern, but it’s not the priority. The priority is addressing the client’s physiological needs first.
Choice B rationale:
Impaired tissue perfusion is the priority nursing diagnosis. Varicose veins with ulcerations and edema indicate poor blood flow, which can lead to tissue damage if not addressed.
Choice C rationale:
Impaired skin integrity is a concern due to the ulcerations, but it’s secondary to impaired tissue perfusion.
Choice D rationale:
Alteration in activity tolerance may be present due to the feeling of heaviness, but it’s not the priority.

A. Check the catheter tubing for kinks or twisting. B. Irrigate the catheter once each shift. C. Clean the perineal area with an antiseptic solution daily. D. Replace the catheter every 3 days.

Correct Answer is A

Explanation

Choice A rationale:
Checking the catheter tubing for kinks or twisting helps to maintain a patent urinary drainage system, preventing urinary stasis that can lead to infection.
Choice B rationale:
Irrigating the catheter once each shift is not recommended as it can introduce bacteria into the bladder.
Choice C rationale:
Cleaning the perineal area with an antiseptic solution daily can disrupt the normal flora and cause irritation, potentially leading to infection.
Choice D rationale:
Replacing the catheter every 3 days is not recommended as it can increase the risk of urinary tract infection.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection?

Correct Answer is A

Explanation

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A nurse is caring for a client who is 2 hr postoperative following a transurethral resection of the prostate (TURP) gland.

Which of the following assessments should the nurse view to be an indication of a postoperative complication?