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 B
Explanation
Choice A reason: Establishing short-term, realistic goals is important, but it should come after assessing the client's current knowledge. Goals should be tailored to the individual's needs and understanding.
Choice B reason: Assessing the client's current knowledge about managing diabetes is crucial as the first step. This allows the nurse to identify any gaps in understanding and to provide education that is specific to the client's needs.
Choice C reason: Providing access to a video about diabetes can be a useful educational tool, but it should not be the first action. The content of the video may not address the client's specific questions or misconceptions.
Choice D reason: Evaluating the effectiveness of the client's admission teaching plan is an ongoing process and should be done after initial education and interventions have been provided.
Correct Answer is C
Explanation
Choice A reason: Metabolic acidosis is characterized by a low pH and a low HCO3. However, George's HCO3 is within normal range, indicating that metabolic acidosis is not the primary issue.
Choice B reason: Partially compensated metabolic acidosis would present with a low pH and a low HCO3, along with a low PaCO2 as the body attempts to compensate. George's PaCO2 is elevated, which is not consistent with this condition.
Choice C reason: George's high PaCO2 and near normal HCO3 suggest that his primary issue is respiratory acidosis. The body has begun to compensate by retaining HCO3, making it partially compensated.
Choice D reason: Uncompensated respiratory acidosis would present with an elevated PaCO2 and a normal HCO3. Since George's HCO3 is elevated, it indicates partial compensation.
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