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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

The correct answer is: d. Hypoglycemia

Choice A reason:

Hyperglycemia: This statement is wrong because hyperglycemia typically presents with symptoms like increased thirst, frequent urination, and fatigue, not sweating and anxiety.

Choice B reason:

Nephropathy: This statement is wrong because nephropathy, a kidney complication, does not cause acute symptoms like sweating and anxiety. It usually presents with proteinuria and progressive kidney dysfunction.

Choice C reason:

Ketoacidosis: This statement is wrong because diabetic ketoacidosis usually presents with symptoms like fruity breath, nausea, vomiting, and deep, rapid breathing (Kussmaul respirations), not sweating and anxiety.

Choice D reason:

Hypoglycemia: This statement is correct because hypoglycemia is characterized by symptoms such as sweating, anxiety, palpitations, and confusion due to the release of adrenaline in response to low blood glucose levels.

A. Arthralgia B. Bradycardia C. Fecal impaction D. Hypertension

Correct Answer is A

Explanation

Choice A reason:
Arthralgia, or joint pain, is a common symptom associated with heterotopic ossification (HO), especially when it occurs near joints. The ectopic bone formation can lead to restricted movement and pain during joint movement.

Choice B reason:
Bradycardia, or a slower than normal heart rate, is not directly associated with HO. While spinal cord injuries can affect autonomic control and potentially lead to bradycardia, it is not a symptom specifically linked to the presence of HO.

Choice C reason:
Fecal impaction may occur in patients with spinal cord injuries due to mobility issues and changes in bowel function, but it is not a direct result of HO. HO does not typically affect bowel movements unless the ossification is in a location that mechanically obstructs the bowel.

Choice D reason:
Hypertension, or high blood pressure, is not a symptom commonly associated with HO. While individuals with spinal cord injuries may experience dysregulation of blood pressure, this is not specifically related to HO.

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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?

Nursing Test Bank

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