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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
Choice A rationale:
The ESR is a common blood test that measures how quickly red blood cells settle at the bottom of a test tube. Inflammation can cause the cells to settle faster, and this test can be used to monitor the effectiveness of anti-inflammatory treatments like aspirin.
Choice B rationale:
The WBC count is a measure of the body’s immune response and is not directly affected by aspirin.
Choice C rationale:
The RF is a specific marker for rheumatoid arthritis, but it does not change with aspirin treatment.
Choice D rationale:
The ANA is a test used to help diagnose autoimmune disorders, and it is not affected by aspirin.
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