A nurse is caring for an older adult client who is 1 hr postoperative following a transurethral resection of the prostate and is receiving continuous bladder irrigation. Which of the following findings should the nurse report to the provider?

Pink-tinged urine

Moderate pain

Decreased urinary output

Client urge to void

Answer and Explanation

The Correct Answer is C

Rationale:

A. Pink-tinged urine: Pink-tinged urine can be a normal finding after a transurethral resection of the prostate (TURP), as it is expected due to the presence of blood in the urine from the procedure. It should improve over time as the bleeding subsides.

B. Moderate pain: Moderate pain is common following TURP, and it typically resolves with appropriate pain management. However, it should still be monitored and managed appropriately.

C. Decreased urinary output: Decreased urinary output is concerning after TURP and could indicate an obstruction, clot retention, or inadequate irrigation flow. This requires immediate attention and should be reported to the provider.

D. Client urge to void: The urge to void after TURP is normal and may occur as the bladder is healing. It may also result from the presence of the catheter. This is not a cause for concern unless accompanied by other signs of complications.

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Correct Answer is D

Explanation

Rationale:

A. Vasovagal bradycardia without syncope: Vasovagal bradycardia, which is often caused by a reflex response to certain triggers, typically does not require a pacemaker. If the client is not experiencing syncope, a pacemaker is generally not indicated.

B. Sinus tachycardia with rates faster than 80/min: Sinus tachycardia is generally not an indication for a pacemaker. A heart rate faster than 80/min is often a physiological response to various conditions, such as exercise or stress, and usually does not require pacing unless.

C. Asymptomatic second-degree AV block: Asymptomatic second-degree AV block does not always require a pacemaker. Many individuals with this type of block do not experience significant symptoms, and treatment may not be necessary unless the block progresses.

D. Complete AV block with rates slower than 40/min: A complete AV block with a heart rate slower than 40/min is a serious condition that often requires the placement of a permanent pacemaker. This type of block disrupts the normal conduction between the atria and ventricles, leading to slow heart rates and inadequate cardiac output.

A. "This finding may indicate possible medication toxicity." B. "This is an expected adverse effect of this medication." C. "You will need to increase your fluid intake to resolve this problem." D. "Your provider will prescribe a different medication regimen."

Correct Answer is B

Explanation

Rationale:

A. "This finding may indicate possible medication toxicity." The red-orange color of the saliva is not indicative of toxicity but is a known, harmless side effect of rifampin. The nurse should reassure the client that this color change is common and not a sign of toxicity.

B. "This is an expected adverse effect of this medication." Rifampin can cause body fluids, including saliva, urine, and sweat, to turn a red-orange color. This is a well-known, expected adverse effect of the medication and does not require discontinuation or interventions.

C. "You will need to increase your fluid intake to resolve this problem." Increasing fluid intake will not affect the color change in body fluids caused by rifampin. The change in color is a benign side effect, and fluid intake does not resolve this issue.

D. "Your provider will prescribe a different medication regimen." The red-orange discoloration is a common side effect of rifampin and is not harmful. There is no need to change the medication regimen unless the client experiences other more serious side effects.

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A nurse is caring for an older adult client who is 1 hr postoperative following a transurethral resection of the prostate and is receiving continuous bladder irrigation. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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