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 B

Explanation

A) Staying current on scheduled immunizations: Staying up-to-date with immunizations is important for overall child health but is not a direct risk factor for sudden infant death syndrome (SIDS). Immunizations can help prevent infections that could contribute to SIDS but are not directly related to the syndrome itself.

B) Maternal smoking during pregnancy: Maternal smoking during pregnancy is a well-documented risk factor for SIDS. Exposure to nicotine and other harmful substances from smoking can affect the baby's respiratory system and increase the likelihood of SIDS.

C) Newborn who is large for gestational age: Being large for gestational age is not a recognized risk factor for SIDS. SIDS risk factors are more closely associated with prenatal and postnatal conditions, rather than birth weight alone.

D) Meconium staining of amniotic fluid: Meconium staining of amniotic fluid is a condition that can indicate fetal distress during labor but is not a direct risk factor for SIDS. It is more related to potential complications during delivery rather than SIDS risk.

A. Aspirin can be given to decrease the fever caused by varicella. B. Maintaining a warm environment decreases the eruption of lesions. C. Varicella has an incubation period of 1 to 3 days. D. An antihistamine can be administered to decrease pruritus.

Correct Answer is D

Explanation

A) Aspirin can be given to decrease the fever caused by varicella: Aspirin should not be used in children with varicella (chickenpox) due to the risk of Reye’s syndrome, a rare but serious condition that can cause liver and brain damage. Instead, acetaminophen or ibuprofen is recommended for fever management in these cases.

B) Maintaining a warm environment decreases the eruption of lesions: Maintaining a warm environment does not affect the eruption of varicella lesions and could potentially exacerbate discomfort. A cool environment and loose, comfortable clothing are preferred to help alleviate itching and discomfort.

C) Varicella has an incubation period of 1 to 3 days: The incubation period for varicella is typically 10 to 21 days after exposure. The shorter period of 1 to 3 days is not accurate for varicella and does not reflect the standard incubation period of this disease.

D) An antihistamine can be administered to decrease pruritus: Antihistamines are effective in managing itching (pruritus) associated with varicella lesions. They can help provide relief from the discomfort caused by the rash, making this an appropriate intervention.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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