A nurse is caring for a client who is two hours postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view as an indication of a postoperative complication?
Oral temperature of 38.2°C (100.76°F).
Output of burgundy colored urine.
An urge to void despite having an indwelling urinary catheter.
Pulse rate of 58/min.
The Correct Answer is B
Choice A reason: An oral temperature of 38.2°C (100.76°F) is slightly elevated but can be expected postoperatively as the body responds to surgical stress. It is not necessarily an indication of a complication unless it rises significantly or is accompanied by other symptoms.
Choice B reason: The output of burgundy colored urine can indicate bleeding in the urinary tract, which is a potential complication after TURP. Normal urine color ranges from pale yellow to deep amber, depending on hydration levels. Burgundy colored urine postTURP could suggest the presence of blood, warranting further assessment and intervention.
Choice C reason: Feeling an urge to void despite having an indwelling urinary catheter can be uncomfortable but is not uncommon after TURP due to irritation of the bladder. It is not typically a sign of a complication unless accompanied by other symptoms such as pain or difficulty urinating once the catheter is removed.
Choice D reason: A pulse rate of 58/min is within the normal resting range for adults, which is typically 60100 beats per minute. A lower than average pulse rate postoperatively might be normal for the patient, especially if they are on medications like betablockers, or it could be a sign of a good fitness level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This choice is incorrect. A stroke involving the right cerebral hemisphere typically affects the left side of the body and can cause problems with spatial and perceptual abilities, not necessarily with language or discrimination of words and letters, which are more commonly associated with left hemisphere strokes⁸.
Choice B reason: Motor retardation is not specific to right hemisphere strokes. While right hemisphere strokes can cause weakness on the left side of the body, the term 'motor retardation' is not commonly used to describe this symptom⁸.
Choice C reason: This choice is incorrect because deficits in the right visual field would suggest a problem with the left cerebral hemisphere, not the right. A right hemisphere stroke typically causes problems with the left visual field⁸.
Choice D reason: This is the correct choice. Individuals with right hemisphere strokes may exhibit poor impulse control, as the right hemisphere is involved in judgment and behavior regulation⁸.
Correct Answer is D
Explanation
Choice A reason: A rosebud like stoma orifice is a normal appearance for a new colostomy, indicating that the stoma is healthy and not in distress.
Choice B reason: Red drainage from a stoma can be normal, especially in the early postoperative period, as the stoma may ooze a small amount of blood. However, if the drainage is excessive or persistent, it should be reported.
Choice C reason: A shiny, moist stoma is also a sign of a healthy stoma. The stoma should be moist and have a pink or red color, similar to the inside of the mouth.
Choice D reason: A purplish colored stoma indicates compromised blood flow and is a sign of ischemia. This is a serious complication that requires immediate medical attention to prevent tissue death.
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