A registered nurse is providing ongoing post-operative care to a client who has had knee surgery. The nurse assesses the surgical dressing and finds it saturated with blood. The client is restless and has a rapid pulse.
What should the nurse do next?

Make assessments every 15 minutes for four hours.

Document the data, remove the old dressing and apply a new dressing.

Apply a well-secured additional pressure dressing and report findings.

Reassure the family that this is a common problem.

Answer and Explanation

The Correct Answer is C

Rationale for Choice A:
Making assessments every 15 minutes for four hours does not directly address the immediate concern of blood loss and potential hemodynamic instability. While close monitoring is essential, it's not the primary action in this situation.
Excessive blood loss can rapidly lead to hypovolemic shock, which requires prompt intervention to prevent serious complications.
Relying solely on frequent assessments without active interventions could delay crucial treatment and compromise patient safety.
Rationale for Choice B:
Documenting the data, removing the old dressing, and applying a new dressing might be necessary at some point, but it's not the most urgent priority in this case.
Removing the dressing could disrupt clot formation and potentially worsen bleeding.
Applying a new dressing without addressing the underlying bleeding might not effectively control the blood loss. Rationale for Choice C:
Applying a well-secured additional pressure dressing is the most appropriate immediate action to help control bleeding and prevent further blood loss.
It provides direct compression to the surgical site, promoting hemostasis and reducing blood flow. This action prioritizes stabilizing the patient's condition and preventing further complications.

Reporting the findings to the healthcare provider is crucial for timely assessment, diagnosis, and management of potential complications, such as hemorrhage or hematoma.
It ensures collaboration with the healthcare team and facilitates appropriate interventions based on the patient's specific needs.
Rationale for Choice D:
Reassuring the family that this is a common problem might provide some comfort, but it doesn't address the patient's immediate needs or the potential severity of the situation.
It's essential to prioritize patient safety and provide interventions to control bleeding, even if bleeding is a known potential complication.
Transparency and clear communication with the family are important, but they should not replace necessary medical interventions.

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Correct Answer is A

Explanation

Urinary retention is the inability to completely empty the bladder. It is a common symptom of BPH, as the enlarged prostate can press on the urethra and obstruct the flow of urine. This can lead to several characteristic symptoms, including:

Feeling of incomplete bladder emptying: Patients often feel as though they haven't fully emptied their bladder, even after urinating.

Straining to urinate: It may take extra effort to initiate and maintain a urine stream.

Weak urine stream: The force of the urine stream may be noticeably reduced.

Intermittent urine stream: The flow of urine may start and stop repeatedly.

Post-void dribbling: Urine may continue to drip after urination has seemingly ended.

Urinary frequency: The need to urinate frequently, often at night (nocturia).

Urgency: A sudden, compelling need to urinate that may be difficult to postpone.

Bladder pain or discomfort: Pressure or pain in the lower abdomen, often associated with a full bladder. Pathophysiology:

Bladder outlet obstruction: The enlarged prostate physically compresses the urethra, the tube that carries urine from the bladder to the outside of the body. This obstruction makes it difficult for urine to flow freely, leading to incomplete bladder emptying.

Detrusor muscle dysfunction: The detrusor muscle, which forms the bladder wall, may become weakened or overactive due to the constant strain of trying to empty against resistance. This can further impair bladder emptying.

Neurological factors: In some cases, nerve damage or dysfunction may contribute to urinary retention, particularly in men with diabetes or neurological conditions.

Additional insights:

Chronic urinary retention can result in serious complications, such as bladder stones, urinary tract infections, and kidney damage.

Acute urinary retention is a medical emergency that requires immediate catheterization to relieve the bladder and prevent further complications.

Treatment for urinary retention typically involves medications to relax the prostate and bladder muscles, as well as lifestyle modifications such as limiting fluid intake before bedtime. In some cases, surgical intervention may be necessary to reduce the size of the prostate or widen the urethra.

A. The urine may be brown or black. B. The urine may be orange or orange-red. C. The urine may be green or blue-green. D. The urine may be blood-tinged.

Correct Answer is B

Explanation

Choice A rationale:

Brown or black urine is not a typical observation associated with Levodopa use. It can indicate other potential causes, such as: Dehydration

Liver disease

Rhabdomyolysis (muscle breakdown)

Certain medications like metronidazole or iron supplements

Hematuria (blood in the urine)

It's essential to rule out these conditions if brown or black urine is observed.

Choice C rationale:

Green or blue-green urine is also not common with Levodopa. It can be caused by:

Medications like amitriptyline, indomethacin, propofol, or methylene blue

Certain food dyes

Urinary tract infections caused by Pseudomonas bacteria

Familial benign hypercalcemia (a rare genetic condition)

Choice D rationale:

Blood-tinged urine (hematuria) is not a direct effect of Levodopa. It can signal underlying urinary tract issues, such as: Infections

Kidney stones

Bladder or kidney tumors

Trauma to the urinary tract

Strenuous exercise

Choice B rationale:

Orange or orange-red urine is the most common observation in patients taking Levodopa. This discoloration is due to: Breakdown of Levodopa into dopamine and other metabolites

These metabolites can impart an orange or reddish hue to the urine

The color intensity may vary depending on dosage and individual metabolism

It's generally harmless and doesn't require medical intervention

However, it's essential to inform healthcare providers about any urine color changes to ensure proper monitoring and rule out other potential causes.

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A registered nurse is providing ongoing post-operative care to a client who has had knee surgery. The nurse assesses the surgical dressing and finds it saturated with blood. The client is restless and has a rapid pulse. What should the nurse do next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the symptom called when a male patient, diagnosed with an enlarged prostate (BPH/benign prostatic hyperplasia), reports not completely emptying his bladder when he voids?

Correct Answer is A

Explanation

A nurse is examining the urine output of a client with Parkinson’s disease who is on the medication Levodopa. Which of the following is a common observation for a client on this medication?

Correct Answer is B

Explanation

A nurse is evaluating a hospitalized client who had an indwelling catheter removed four days ago. Which assessment findings suggest that this client has developed a Urinary Tract Infection (UTI)? Select all that apply.

A nurse is using a bladder scanner to assess the bladder volume of a client with urinary frequency. In which position would the nurse place the client?

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A nurse is using a bladder scanner to measure the bladder volume of a patient who is experiencing frequent urination. In what position should the nurse place the patient?

The client has an open wound on the right ankle that the registered nurse has cleansed and dressed with gauze. The nurse now needs to apply a conforming ace bandage to keep the dressing in place. What technique will the nurse use to apply the bandage on the ankle?

An elderly resident of a long-term care facility frequently wakes up to urinate during the night. What physiological change associated with normal aging could be the cause of this?

A registered nurse is providing ongoing post-operative care to a client who has had knee surgery. The nurse assesses the surgical dressing and finds it saturated with blood. The client is restless and has a rapid pulse. What should the nurse do next?

A client with urine retention due to a complete prostatic obstruction requires a urinary catheter to drain the bladder. Which type of urinary catheter is most suitable for a client with an obstructed urethra?

A registered nurse is providing ongoing post-operative care to a client who has had knee surgery. The nurse assesses the surgical dressing and finds it saturated with blood. The client is restless and has a rapid pulse.
What should the nurse do next?