A nurse is preparing a client for surgery. Which of the following is a priority when completing an assessment preoperatively?
To determine understanding of the procedure
To establish the need for psychological support
To identify possible surgical risks
To recognize resources needed postoperatively
The Correct Answer is C
Choice A reason:
Determining the client's understanding of the procedure is important as it ensures informed consent and can help alleviate anxiety. However, while this is a necessary part of preoperative care, it may not be the immediate priority¹.
Choice B reason:
Establishing the need for psychological support is a valuable aspect of holistic care. It addresses the client's emotional well-being and can improve overall satisfaction with the surgical experience. Nonetheless, it is not the primary focus of the preoperative assessment².
Choice C reason:
Identifying possible surgical risks is the priority in a preoperative assessment. This includes evaluating the client's medical history, current health status, and any factors that could increase the risk of complications during or after surgery. A thorough risk assessment is crucial for planning safe surgical care and for making decisions about proceeding with the surgery¹³.
Choice D reason:
Recognizing resources needed postoperatively is part of discharge planning and is essential for ensuring continuity of care. While it is an important consideration, it is not the immediate priority during the preoperative assessment².
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Correct Answer is B
Explanation
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.
Correct Answer is D
Explanation
Choice A reason:
Hyperplasia is an increase in the number of cells in an organ or tissue, which can lead to its enlargement. While hyperplasia can be a response to a stimulus and is not necessarily precancerous, it does not describe the abnormal changes in the shape, size, and organization of mature cells.
Choice B reason:
Metaplasia is a reversible change in which one differentiated cell type is replaced by another cell type. This process can be a response to chronic irritation and inflammation, and while it may predispose cells to cancerous changes, it is not in itself a precancerous condition.
Choice C reason:
The term 'malignant' refers to cancerous cells that have the ability to invade and destroy nearby tissue and spread to other parts of the body. The description of the cells as 'moderately abnormal' does not indicate that the cells are malignant but rather that they are showing signs of potentially precancerous changes.
Choice D reason:
Dysplasia refers to the presence of abnormal cells within a tissue or organ. It is characterized by changes in cell size, shape, uniformity, arrangement, and structure, particularly when such changes are strongly suggestive of developing neoplasia, or new, abnormal growth. In the context of a Pap smear, dysplasia is indicative of precancerous changes and is the term used to describe the abnormal development of cells on the cervix.
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