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A nurse is caring for a client who is day post-op following a transurethral resection of the prostate (TURP) and has a continuous bladder irrigation in place. Which actions should the nurse take? (Select a that apply)

Add the amount of bladder irrigation to the total output

Notify the surgeon if the urine is bright red an appearance or has large clots

Use sterile technique when preparing the irrigation solution.

Contact the surgeon if the client reports a continual need to void.

Ensure the drainage tubing is patent and without obstruction.

Answer and Explanation

Correct Answer : A,B,E

A. The amount of irrigation fluid used must be added to the total output to accurately calculate fluid balance.

B. Bright red urine or large clots may indicate bleeding, which should be reported to the surgeon immediately.

C. Irrigation solution preparation does not require sterile technique; clean technique is sufficient for this task.

D. A continual need to void could be a normal post-op symptom, but if it persists or is severe, it should be investigated.

E. Ensuring the drainage tubing is patent and unobstructed is essential for proper urine flow and preventing complications.

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Correct Answer is A

Explanation

A. The 78-year-old male with chronic kidney disease who develops a new nonproductive cough and shortness of breath is concerning for pulmonary edema or fluid overload, which can rapidly progress and require immediate attention.

B. The 37-year-old female with cellulitis is experiencing warmth in the affected leg, which is expected with cellulitis and may indicate the need for monitoring but is not as urgent as the other options.

C. The 70-year-old male who underwent a TURP is having a burning sensation during urination, which is a common postoperative finding and is not as concerning unless other complications arise.

D. The 52-year-old female with pancreatitis and abdominal pain rated 7 is in pain but is stable, and this pain can typically be managed with pain medication and monitoring, so she is not the most urgent.

A. This occurred because there was an obstruction of urine flow from the kidneys B. This occurs because there was a decrease in blood flow to the kidneys C. This occurred because there was structural damage to the kidneys resulting in acute tubular necrosis D. This occurred because a blood cat formed in the kidneys

Correct Answer is B

Explanation

A. Obstruction of urine flow can lead to prerenal or postrenal acute kidney injury, but hypovolemic shock is a cause of decreased blood flow to the kidneys, not obstruction.

B. Hypovolemic shock leads to decreased blood flow to the kidneys, which can cause acute renal failure. This is the most appropriate cause of acute renal failure in the context of hypovolemic shock.

C. Acute tubular necrosis is a result of prolonged ischemia or direct kidney injury and may follow decreased blood flow, but the primary cause in this case is hypovolemic shock.

D. A blood clot in the kidneys may cause acute renal failure but is not the typical cause in hypovolemic shock.

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A nurse is caring for a client who is day post-op following a transurethral resection of the prostate (TURP) and has a continuous bladder irrigation in place. Which actions should the nurse take? (Select a that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The night nurse on a medical floor has just received report on several patients. On which of the following clients should the nurse make rounds FIRST?

Correct Answer is A

Explanation

A client in acute renal failure has been admitted into the Med Surgical ICU due to hypovolemic shock. The client's family asks the nurse why the client has developed acute renal failure. The nurse's best response is?

Correct Answer is B

Explanation

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