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:Scheduling the procedure five days before the expected menses would place it in the late proliferative phase, which risks missing ongoing menstrual bleeding and could coincide with implantation if the client ovulated early. Best practice is to perform the test after menstruation ends but before ovulation—usually within 12 days of the first day of the last period—to ensure the client is not pregnant.
Choice B reason:
Diarrhea is not a common side effect of HSG. The procedure involves the insertion of a dye into the uterine cavity to visualize the fallopian tubes and uterus via X-ray. While some discomfort, cramping, or spotting may occur, diarrhea is not typically expected.
Choice C reason:
There is no requirement for a client to be on a liquid diet following an HSG procedure. The client can usually resume normal activities and diet immediately after the procedure unless otherwise instructed by their healthcare provider.
Choice D reason:
Referred shoulder pain can occur when contrast fluid spills through a patent tube into the peritoneal cavity, irritating the diaphragm’s undersurface and eliciting pain perceived at the shoulder via the phrenic nerve. Clients should be advised this is normal, short-lived, and relieved by positioning or mild analgesics.
Correct Answer is D
Explanation
Choice A reason:
Annular lesions are ring-shaped with a clear center, which does not describe a lesion with a wavy border. This term is typically used for lesions like ringworm, which present as circular rashes with normal skin in the center.
Choice B reason:
Circinate lesions are also circular but are not characterized by a wavy border. They are similar to annular lesions but often have a more rounded edge and are associated with conditions like psoriasis.
Choice C reason:
Coalesced lesions refer to multiple lesions that have merged to form a larger one. While they can have irregular borders, 'coalesced' does not specifically describe the wavy nature of the border.
Choice D reason:
Serpiginous lesions have a wavy or snake-like border, which matches the description provided by the nurse. This term is often used for parasitic infections, such as cutaneous larva migrains, which create a trail-like pattern on the skin.
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