A nurse is collecting data on a client who is postoperative following a transurethral resection of the prostate (TURP). The nurse should recognize which of the following findings is the priority?
The client has small blood clots in his urinary catheter.
The client reports a continuous urge to void.
The client reports burning around the urinary catheter.
The client has bright red urine in his urinary catheter.
The Correct Answer is D
Choice A rationale
Small blood clots in the urinary catheter are common after TURP and usually resolve on their own. They are not typically a cause for immediate concern unless they persist or cause blockage.
Choice B rationale
A continuous urge to void is a common symptom after TURP due to irritation of the bladder and urethra. It is uncomfortable but not usually a priority concern.
Choice C rationale
Burning around the urinary catheter can occur due to irritation or infection. While it needs to be addressed, it is not the most critical finding.
Choice D rationale
Bright red urine in the urinary catheter indicates active bleeding, which can be a sign of a serious complication such as hemorrhage. This requires immediate attention to prevent further blood loss and potential shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Consuming alcohol before bed can worsen GERD symptoms by relaxing the lower esophageal sphincter and increasing acid reflux.
Choice B rationale
Eating a snack before bed can increase the likelihood of acid reflux during sleep, as lying down shortly after eating can promote reflux.
Choice C rationale
Elevating the head of the bed helps reduce acid reflux by keeping stomach acid from flowing back into the esophagus during sleep.
Choice D rationale
Sleeping on the stomach with the head flat can exacerbate GERD symptoms by increasing pressure on the stomach and promoting acid reflux.
Correct Answer is B
Explanation
Choice A rationale
Monitoring intake and output is important but not the first priority. The immediate concern is to address the client’s pain.
Choice B rationale
Administering pain medication is the first priority. Managing the client’s pain will help alleviate discomfort and allow for further assessment and treatment.
Choice C rationale
Ambulating in the hall is not appropriate for a client experiencing flank pain and nausea. It could exacerbate the symptoms.
Choice D rationale
Straining the urine is important for identifying any stones, but it is not the first priority. Pain management should be addressed first.
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