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 A
Explanation
A. This is the correct answer. Bladder perforation is a significant complication that requires immediate attention. The nurse should inform the surgical team to address the situation promptly.
B. Notifying the client's family about the complication is not the immediate action. The priority is to inform the surgical team and manage the situation.
C. While documentation is essential, it is not the immediate action required in this critical situation.
D. Administering pain medication may be necessary, but the priority is to address the bladder perforation and involve the surgical team to manage the complication.
Correct Answer is D
Explanation
A) Resuming heavy lifting and strenuous exercises immediately after TURP surgery can lead to complications such as bleeding or wound disruption.
B) This is the correct answer. The client should avoid heavy lifting and strenuous exercises for at least six to eight weeks after surgery to allow for proper healing and to prevent complications.
C) Resuming heavy lifting and strenuous exercises just two days after surgery is not recommended as the body needs time to heal.
D) Avoiding heavy lifting and strenuous exercises for one week may not be sufficient for proper healing after TURP surgery.
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