A nurse is planning care for a client who is 2 hours postoperative following a transurethral resection of the prostate (TURP). The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?
Restrict the client's oral fluid intake.
Remind the client he might feel a constant urge to void.
Monitor the client's urine output every 6 hours.
Weigh the client every evening.
The Correct Answer is B
Choice A reason:
Restricting the client's oral fluid intake is not typically recommended as part of postoperative care following TURP. In fact, maintaining adequate hydration is important to help flush the bladder and prevent clot formation.
Choice B reason:
It is common for clients to feel a constant urge to void due to the irritation of the bladder from the catheter and the continuous bladder irrigation. Reminding the client that this sensation is normal and expected can help alleviate anxiety and provide reassurance.
Choice C reason:
Monitoring the client's urine output is important to ensure that the bladder irrigation is effective and that there are no signs of obstruction. However, it should be done more frequently than every 6 hours, especially in the immediate postoperative period, to promptly detect any complications.
Choice D reason:
Weighing the client every evening is not directly related to the management of continuous bladder irrigation. While monitoring weight can be part of overall postoperative care, it does not address the specific needs related to TURP and continuous bladder irrigation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Ecchymosis, or bruising, of the surrounding skin is a common finding associated with fractures due to the trauma to blood vessels in the area. While it can indicate bleeding or injury, ecchymosis itself does not specifically indicate impaired venous return.
Choice B reason:
Acute pain is a typical symptom following a fracture and results from the injury to the bone and surrounding tissues. Pain is an expected finding and does not directly suggest an issue with venous return.
Choice C reason:
A bounding distal pulse may actually suggest increased arterial flow or could be a sign of other conditions such as high blood pressure or fever. It does not indicate impaired venous return, which is typically characterized by a lack of pulse or a very weak pulse.
Choice D reason:
Increasing edema, or swelling, in the affected arm is a sign of impaired venous return. When veins are unable to effectively return blood to the heart, fluid can accumulate in the tissues, leading to edema. In the context of a fracture, this could be due to compression or damage to the veins, which can impede blood flow and result in swelling.
Correct Answer is ["B","C"]
Explanation
The correct answer is b. Minimize skin exposure to moisture and c. Use pillows to keep heels off the bed surface.
Choice A reason:
a. Massage over erythematous bony prominences: This is incorrect because massaging erythematous (reddened) areas can cause further tissue damage and exacerbate skin breakdown.
Choice B reason:
b. Minimize skin exposure to moisture: This is correct. Moisture can lead to skin maceration, increasing the risk of skin breakdown. Keeping the skin dry helps maintain its integrity.
Choice C reason:
c. Use pillows to keep heels off the bed surface: This is correct. Elevating the heels reduces pressure on them, preventing pressure ulcers.
Choice D reason:
d. Implement a turning schedule every 4 hours: This is incorrect. To prevent pressure injuries, turning should be done every 2 hours, not every 4 hours.
Choice E reason:
e. Keep the client’s skin dry with powder: This is incorrect. Powder can cause skin irritation and breakdown.
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