A nurse is planning care for a client who is 2 hr postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?

Remind the client he might feel a constant urge to void.

Weigh the client every evening.

Monitor the client's urine output every 6 hr.

Restrict the client's oral fluid intake.

Answer and Explanation

The Correct Answer is A

A. Clients receiving continuous bladder irrigation after a transurethral resection of the prostate (TURP) often feel a constant urge to void due to the presence of the catheter and the irrigation fluid in the bladder. The nurse should reassure the client that this sensation is expected.

B. Weighing the client is not necessary for immediate postoperative care following TURP. Fluid balance is managed by monitoring urine output rather than daily weight.

C. Urine output should be monitored more frequently than every 6 hours in the immediate postoperative period, especially with continuous bladder irrigation, to ensure there are no blockages or complications.

D. Fluid restriction is not recommended after TURP. In fact, encouraging oral fluid intake helps maintain hydration and prevents blood clots in the bladder irrigation system.

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Correct Answer is D

Explanation

A. Requesting an indwelling urinary catheter is not appropriate for preventing skin breakdown; catheters can increase the risk of urinary tract infections and skin irritation.

B. Cleaning the skin and perineum with hot water can cause irritation and dryness. Instead, using mild soap and warm water is recommended for cleaning.

C. Checking the client's skin every 8 hours may not be frequent enough for a client with incontinence, as more frequent assessments are needed to catch signs of breakdown early.

D. Applying a moisture barrier ointment to the skin protects it from moisture and irritants, helping to prevent skin breakdown in clients with urinary incontinence. This action is proactive and aligns with best practices for skin care.

A. A 5-year-old female who is a quadriplegic. B. A 5-year-old with a Braden Scale score of 7. C. A 5-year-old female who has controlled diabetes and is ambulating three times a day. D. A 35-year-old male with a BMI of 13.6 that is incontinent of stool and has a right leg splint.

Correct Answer is ["A","B","D"]

Explanation

A. A quadriplegic client is at high risk for pressure injuries due to immobility and lack of sensation, which can lead to prolonged pressure on skin and tissues.

B. A Braden Scale score of 7 indicates severe risk for pressure injuries. The lower the Braden score, the higher the risk, with scores less than 9 signifying very high risk.

C. A client with controlled diabetes who is ambulating frequently is not at high risk for pressure injuries because mobility reduces the risk of sustained pressure.

D. A BMI of 13.6 indicates severe underweight status, and incontinence of stool increases moisture, both of which elevate the risk of pressure injuries. Additionally, the splint on the leg may create pressure points.

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A nurse is planning care for a client who is 2 hr postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

Correct Answer is D

Explanation

You're working on a medical surgical floor. You have the following patients below. Select all the patients below that are at risk for a pressure injury: (Select All that Apply.)

Correct Answer is ["A","B","D"]

Explanation

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