A nurse is providing preoperative teaching to a client who is to undergo a transurethral resection of the prostate to treat benign prostatic hypertrophy. Which of the following client statements should the nurse identify as an understanding of the teaching?

"I will expect to have to strain while having a bowel movement."

"I'll plan to restrict my fluid intake to 1 liter per day."

"I might have the urge to urinate while I have the catheter in place."

"I'll keep my leg flexed if the catheter is taped to my leg."

Answer and Explanation

The Correct Answer is C

A) "I will expect to have to strain while having a bowel movement":
Straining during bowel movements should be avoided as it can increase abdominal pressure and strain on the surgical site, potentially leading to complications such as bleeding or increased discomfort.

B) "I'll plan to restrict my fluid intake to 1 liter per day":
Fluid restriction is not typically advised after a transurethral resection of the prostate (TURP). Adequate fluid intake is important to help flush the bladder and reduce the risk of blood clots and urinary tract infections.

C) "I might have the urge to urinate while I have the catheter in place":
It is common for clients to feel the urge to urinate while a catheter is in place due to the pressure of the catheter on the bladder neck. This statement indicates an understanding of the postoperative experience and normal sensations.

D) "I'll keep my leg flexed if the catheter is taped to my leg":
Keeping the leg flexed is not necessary for catheter management. The catheter should be securely taped to the leg to prevent movement and minimize discomfort, but the position of the leg is not a critical factor in its management.

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Correct Answer is D

Explanation

A) Discontinue the overhead trapeze:
The overhead trapeze can be beneficial for the client to assist with repositioning and mobility, especially postoperatively. Removing it would hinder the client's ability to move independently and could increase the risk of complications from immobility.

B) Turn the client every 6 hr while in bed:
Turning the client every 6 hours is insufficient for preventing complications such as pressure ulcers. Standard care involves repositioning the client at least every 2 hours to maintain skin integrity and promote circulation.

C) Remind the client that phantom limb pain does not need treatment:
Phantom limb pain is a real and often distressing condition for many amputees. It requires appropriate treatment and management strategies to ensure the client's comfort and psychological well-being. Dismissing the pain can lead to increased distress and hinder recovery.

D) Assist the client to a prone position every 3 hr:
Positioning the client in a prone position regularly helps prevent contractures, particularly hip flexion contractures, which are common after lower limb amputations. This position can stretch the hip muscles and aid in maintaining proper alignment and mobility, making it a beneficial intervention in postoperative care.

A. Give a 25-mg test dose of the medication. B. Flush the IV site with 3 mL of heparin following infusion. C. Instruct the client to remain supine for 10 min after administration. D. Dilute the medication in sterile water for injection.

Correct Answer is D

Explanation

A) Drowsiness: While drowsiness can be a sign of elevated magnesium levels, it is less critical compared to more immediate symptoms like bradycardia. Monitoring and managing drowsiness is important, but bradycardia poses a more immediate risk of severe cardiovascular issues.

B) Diminished patellar reflexes: Diminished reflexes can indicate elevated magnesium levels, but this finding is less urgent compared to symptoms directly affecting heart function. It still needs to be reported but is not the highest priority.

C) Generalized muscle weakness: Muscle weakness is another common sign of high magnesium levels, reflecting the effect of magnesium on neuromuscular function. However, it is less critical compared to bradycardia, which can be life-threatening.

D) Bradycardia: Elevated magnesium levels can significantly impact cardiac function, leading to bradycardia. Bradycardia can be life-threatening, as it may result in decreased cardiac output and potential for severe complications. Therefore, this finding requires immediate attention and should be reported to the provider first.

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A nurse is providing preoperative teaching to a client who is to undergo a transurethral resection of the prostate to treat benign prostatic hypertrophy. Which of the following client statements should the nurse identify as an understanding of the teaching?

Nursing Test Bank

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