A nurse is caring for a client who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse to report to the provider?
Emesis of 100 mL
Oral temperature of 37.5" C (99.5° F)
Pain level of 4 on a 0 to 10 rating scale
Thick, red-colored urine
The Correct Answer is D
a. Emesis of 100 mL: While emesis is a concern, the priority is to address potential complications related to the surgical procedure first.
b. Oral temperature of 37.5" C (99.5° F): This temperature is within a normal range, and it is not an immediate concern.
c. Pain level of 4 on a 0 to 10 rating scale: Pain is important to address, but the priority is to assess for potential complications such as bleeding or infection.
d. Thick, red-colored urine: This finding suggests the possibility of bleeding, which could be a complication of the TURP procedure. It is the priority finding to report to the provider for further evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Bradycardia: Atenolol is a beta-blocker that can slow down the heart rate, leading to
bradycardia. Monitoring the client for signs of bradycardia, such as dizziness, fatigue, or fainting, is important.
b. Anemia: Atenolol is not known to cause anemia. Monitoring for anemia is not a specific concern with this medication.
c. Hypokalemia: Atenolol is not associated with causing hypokalemia. However, beta-blockers in general may affect potassium levels indirectly.
d. Neutropenia: Atenolol is not typically associated with causing neutropenia. Monitoring for neutropenia is not a specific concern with this medication.
Correct Answer is D
Explanation
a. Position the client flat in bed: This position may increase pressure on the abdomen and exacerbate ascites. The head of the bed should be elevated to enhance respiratory function.
b. Weigh the client weekly: Weighing the client daily is more appropriate to monitor fluid retention and assess the effectiveness of interventions.
c. Medicate the client with acetaminophen for discomfort: While acetaminophen can be used for pain relief, its use should be monitored closely due to the potential for liver toxicity in clients with cirrhosis.
d. Measure the client’s abdominal girth every 8 hours: Monitoring abdominal girth is crucial for assessing the degree of ascites and evaluating the effectiveness of interventions.
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