A nurse is providing postoperative care to a client after TURP surgery. What is the priority assessment for the client during the immediate postoperative period?
Assessing pain level and administering pain medication as needed.
Monitoring vital signs and assessing for signs of hemorrhage.
Evaluating the client's urinary output and catheter patency.
Assessing the client's surgical incision for signs of infection.
The Correct Answer is B
A. Assessing pain level and administering pain medication is important, but the priority during the immediate postoperative period is to monitor vital signs and assess for signs of hemorrhage or other complications.
B. This is the correct answer. Monitoring vital signs and assessing for signs of hemorrhage, such as continuous bright red bleeding, tachycardia, and hypotension, is essential to detect and address any complications promptly.
C. Evaluating the client's urinary output and catheter patency is important but may not be the immediate priority if there are concerns about hemorrhage or other complications.
D. Assessing the client's surgical incision for signs of infection is essential, but it may not be the immediate priority during the immediate postoperative period. The focus should be on assessing vital signs and for signs of bleeding or other complications.
Questions
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While encouraging fluid intake is important, severe pain during urination and inability to void after TURP surgery require further evaluation and intervention by the healthcare provider.
B. This is the correct answer. Severe pain and inability to void after TURP surgery may indicate a complication or urinary retention that requires immediate attention from the healthcare provider.
C. Documenting the client's complaints is essential, but the nurse should not delay notifying the healthcare provider about the client's symptoms.
D. Instructing the client to perform Kegel exercises is not the priority when the client is experiencing severe pain and inability to void after TURP surgery. The client's symptoms require prompt evaluation and intervention.
Correct Answer is C
Explanation
A. Increasing fluid intake may not be necessary before TURP surgery and could lead to over-distension of the bladder, making catheterization difficult.
B. Limiting fluid intake is not recommended as the client needs adequate hydration before surgery to support the body's normal functions.
C. This is the correct answer. Emptying the bladder completely before TURP surgery helps reduce the risk of infection and prevents complications during the procedure.
D. Kegel exercises are beneficial for pelvic floor muscle strengthening but are not specifically required before TURP surgery.
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