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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) "Central vision loss is affected first.": This statement is accurate as macular degeneration primarily affects the macula, which is responsible for central vision. Clients with macular degeneration typically experience a loss of central vision first, which can severely impact activities such as reading, driving, and recognizing faces.
B) "Straining during a bowel movement can increase the progression of the disease.": This statement is not supported by evidence related to macular degeneration. While general health and avoiding strain are important, there is no specific connection between straining during bowel movements and the progression of macular degeneration.
C) "Plan to include high doses of Vitamin E in your diet.": Although antioxidants like Vitamin E can be beneficial for eye health, especially in the context of a balanced diet including other vitamins and minerals, there is no specific recommendation for high doses of Vitamin E alone to manage macular degeneration. The AREDS (Age-Related Eye Disease Study) formulation includes a combination of vitamins and minerals.
D) "Remove glasses before performing the Amsler grid test at home.": When using the Amsler grid test to monitor for changes in vision due to macular degeneration, clients should wear their glasses or contact lenses to ensure they are viewing the grid with their usual visual correction. This helps in accurately detecting any distortions or changes in vision.
Correct Answer is D
Explanation
A) "This medication might cause urinary frequency": Meclizine is not commonly associated with urinary frequency. It is an antihistamine used primarily to manage symptoms of vertigo and motion sickness rather than affecting urinary function.
B) "This medication might cause an increase in your blood sugar": Meclizine does not typically affect blood sugar levels. Concerns about blood sugar levels are more relevant to other medications, such as corticosteroids or certain antihypertensives, rather than meclizine.
C) "This medication might cause you to have excess saliva": Excess saliva is not a common side effect of meclizine. Antihistamines like meclizine usually have the opposite effect, potentially causing dry mouth rather than an increase in saliva.
D) "This medication might cause drowsiness": Drowsiness is a known side effect of meclizine, as it is an antihistamine with sedative properties. This effect can be significant for some individuals, so it's important for clients to be aware of this potential impact on their daily activities.
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