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 C
Explanation
Choice A reason: This is incorrect. While gentle hair care is important, it is not as critical as sun protection for SLE patients.
Choice B reason: This is incorrect. Powder can be drying, and SLE patients often need to keep their skin moisturized.
Choice C reason: This is correct. SLE patients are often photosensitive and need to protect their skin from UV rays.
Choice D reason: This is incorrect. SLE patients should keep their skin well moisturized to prevent dryness.
Correct Answer is ["A","B","D"]
Explanation
Choice A reason: Blowing the nose gently is advised to prevent nosebleeds, which can be a risk due to thrombocytopenia.
Choice B reason: Lubricating lips with water-soluble ointment can prevent cracking and bleeding, which is important for a patient with thrombocytopenia.
Choice C reason: Using a straightedge razor is not recommended because it can increase the risk of cuts and bleeding. An electric razor would be safer.
Choice D reason: Brushing teeth with a soft toothbrush is recommended to prevent gum bleeding due to the low platelet count associated with thrombocytopenia.
Choice E reason: Limiting fruit consumption is not necessary for thrombocytopenia unless the patient has a specific condition that requires dietary restrictions.
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