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

Answer and Explanation

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.

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Correct Answer is B

Explanation

a. Asthma: While asthma can cause dyspnea and fatigue, it is not typically associated with tachycardia and edema.

b. Heart failure: Heart failure is characterized by symptoms such as dyspnea, fatigue,

tachycardia, and edema. Tachycardia may be a compensatory response to maintain cardiac output, and edema can result from fluid retention.

c. Aortic valve regurgitation: Aortic valve regurgitation may cause symptoms such as dyspnea and fatigue, but it is not typically associated with tachycardia and edema.

d. Aortic stenosis: Aortic stenosis may lead to symptoms such as dyspnea, but tachycardia and edema are not typical features of aortic stenosis.

A. Potassium level of 3.0 mEq/L B. Heart rate of 66/min C. BP of 132/82 mm Hg D. Digoxin level of 1.2 ng/ml

Correct Answer is A

Explanation

a. Potassium level of 3.0 mEq/L: Hypokalemia is a potential adverse effect of digoxin, and a

potassium level of 3.0 mEq/L is below the normal range. Low potassium levels can increase the risk of digoxin toxicity.

b. Heart rate of 66/min: A heart rate of 66/min is within the normal range. Digoxin is used to

treat conditions like atrial fibrillation, and the heart rate should be within an appropriate range for the client's condition.

c. BP of 132/82 mm Hg: Blood pressure within the normal range does not require immediate reporting in the context of digoxin administration.

d. Digoxin level of 1.2 ng/ml: The digoxin level of 1.2 ng/ml is within the therapeutic range, and it does not require immediate reporting.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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