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 D

Explanation

A) Reports intolerance to heat: Intolerance to heat is more commonly associated with conditions like hyperthyroidism rather than iron-deficiency anemia. Individuals with iron-deficiency anemia often experience fatigue and cold intolerance due to decreased oxygen-carrying capacity of the blood.

B) Develops bradycardia after eating: Bradycardia (slow heart rate) is not typically associated with iron-deficiency anemia. Anemia usually causes an increased heart rate (tachycardia) as the body tries to compensate for reduced oxygen delivery.

C) Has a friction rub on auscultation: A friction rub is a sound heard on auscultation associated with pericarditis, an inflammation of the pericardium, and is not a typical finding in iron-deficiency anemia. Anemia primarily affects the blood and does not usually cause inflammation of the heart lining.

D) Displays dyspnea while walking: Dyspnea, or shortness of breath, is a common symptom of iron-deficiency anemia, particularly with exertion. This occurs because the reduced hemoglobin levels result in decreased oxygen delivery to tissues, making physical activities more challenging and causing breathlessness.

A. Antimicrobial medication can decrease the severity of symptoms. B. Postherpetic nerve pain can occur in older adult clients. C. Lesions often occur inside the oral cavity of clients who have this infection. D. Cellulitis is a common manifestation in clients who have this infection.

Correct Answer is B

Explanation

A. Antimicrobial medication can decrease the severity of symptoms.: Antiviral medications, rather than antimicrobial ones, are used to reduce the severity and duration of herpes zoster (shingles). They work best when started within 72 hours of the rash appearing.

B. Postherpetic nerve pain can occur in older adult clients.: Postherpetic neuralgia (PHN) is a common complication of herpes zoster, especially in older adults. It is characterized by persistent pain in the area where the shingles rash occurred.

C. Lesions often occur inside the oral cavity of clients who have this infection.: Herpes zoster typically causes a painful rash that appears on one side of the body, often in a band or strip, rather than inside the oral cavity. Oral lesions are more characteristic of herpes simplex virus infections.

D. Cellulitis is a common manifestation in clients who have this infection.: Cellulitis is not a typical manifestation of herpes zoster. Herpes zoster is characterized by a vesicular rash and pain along a dermatomal distribution, not by cellulitis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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