A nurse is providing postoperative care for a client following a transurethral resection of the prostate to treat benign prostatic hypertrophy. Which of the following actions should the nurse take?

Maintain the client on bed rest for 48 hr following surgery.

Check the tubing for kinks and blood clots at least every 2 hr.

Irrigate the client's bladder continuously using 5% dextrose in Ringer's lactate.

Remove the catheter if the client reports severe bladder spasms.

Answer and Explanation

The Correct Answer is B

A) Maintain the client on bed rest for 48 hr following surgery: While some bed rest is recommended initially post-surgery, maintaining bed rest for 48 hours is excessive and can increase the risk of complications like deep vein thrombosis. Early mobilization is generally encouraged to enhance recovery.

B) Check the tubing for kinks and blood clots at least every 2 hr: Regularly checking the catheter tubing for kinks and blood clots is essential to ensure the continuous flow of urine and prevent catheter blockage. This can help in reducing the risk of complications such as bladder distension and urinary retention.

C) Irrigate the client's bladder continuously using 5% dextrose in Ringer's lactate: Continuous bladder irrigation is often done post-TURP to prevent clot formation, but 5% dextrose in Ringer's lactate is not the recommended solution. Typically, normal saline is used to minimize the risk of electrolyte imbalance and maintain the correct osmolarity.

D) Remove the catheter if the client reports severe bladder spasms: Severe bladder spasms can occur post-TURP, but removing the catheter is not the immediate solution. The catheter is necessary for drainage and should be managed with antispasmodic medications or adjusting the irrigation flow rather than removal.

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Correct Answer is C

Explanation

A) "I should make sure that most of my meals contain fried foods to maintain my calorie count": Fried foods are generally high in fat and can be difficult to digest, particularly for individuals with malabsorption syndrome. They are not recommended as a primary source of calories due to their potential to exacerbate gastrointestinal symptoms.

B) "I should change to a gluten-free diet to rest my bowel": A gluten-free diet is beneficial for individuals with celiac disease, but it is not universally required for all inflammatory bowel diseases. The decision to adopt a gluten-free diet should be based on specific medical advice rather than general guidelines for inflammatory bowel disease.

C) "I should try to limit foods containing lactose to prevent bloating and cramping": Limiting lactose-containing foods is a common recommendation for individuals with malabsorption syndrome, especially if lactose intolerance is present. Lactose can exacerbate bloating and cramping, so managing intake can help alleviate these symptoms.

D) "I should eat a high-fiber diet daily to decrease my episodes of flare-ups": High-fiber diets are not always recommended for individuals with inflammatory bowel disease, as fiber can exacerbate symptoms and contribute to flare-ups. A low-fiber or modified fiber diet may be more appropriate depending on the individual’s symptoms and disease state.

A. Painful vesicles along a dermatome B. Acneiform nodules on the face C. Wheals surrounding raised bite marks D. Raised, linear burrows

Correct Answer is D

Explanation

A) Painful vesicles along a dermatome:
This finding is typically associated with herpes zoster (shingles), not scabies. Shingles causes painful vesicles that follow the path of a nerve and are confined to one side of the body, which does not align with the presentation of scabies.

B) Acneiform nodules on the face:
Acneiform nodules are related to conditions such as acne vulgaris, not scabies. Scabies does not typically present with acne-like lesions on the face but rather with intense itching and a specific rash.

C) Wheals surrounding raised bite marks:
Wheals and bite marks are more indicative of insect bites or conditions like urticaria (hives). Scabies is caused by mites that burrow under the skin, leading to a different type of rash.

D) Raised, linear burrows:
Raised, linear burrows are characteristic of scabies. These burrows are caused by the female mite as it tunnels just under the skin to lay eggs, resulting in a distinctive rash and intense itching, especially at night.

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Nursing Test Bank

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