Exhibits

The nurse performs an initial focused assessment of the client. Based on the client's history and assessment data, the nurse's hypothesis is that the client's vital signs are most likely the result of a disease process, medication use, or neither. Each column must have at least one, but may have more than one answer selected.

Choice A reason: Administering a PRN dose of an antispasmodic agent can help relieve bladder spasms that often occur after TURP, but it does not address the immediate issue of blood clots blocking the drainage tubing. The primary concern is to ensure the patency of the catheter and proper drainage.

Choice B reason: Increasing the flow of the bladder irrigation is the best initial action. By increasing the flow, the nurse can help flush out the blood clots from the drainage tubing and ensure that the catheter remains patent. This action directly addresses the problem of blocked drainage and prevents further complications.

Choice C reason: Measuring the client's intake and output is important for overall monitoring, but it does not directly address the immediate concern of blood clots in the drainage tubing. Ensuring proper drainage is crucial to prevent complications such as bladder distention and further bleeding.

Choice D reason: Providing additional oral fluid intake is beneficial for maintaining hydration and promoting urine output, but it does not solve the problem of blood clots in the drainage tubing. The primary focus should be on ensuring the catheter's patency through irrigation.

Temperature: 98.9°F

• Neither Disease Process Nor Medication Use:
  The temperature is within normal range and does not indicate an infection or other abnormality.

Heart Rate: 112 beats per minute

• Disease Process:
  The elevated heart rate (tachycardia) is most likely due to the asthma attack, which increases respiratory effort and oxygen demand. Anxiety from the attack could also contribute.

Respirations: 28 breaths per minute

• Disease Process:
  The elevated respiratory rate (tachypnea) is consistent with the asthma attack and respiratory distress, a hallmark of the disease process.

Blood Pressure: 130/86 mmHg

• Neither Disease Process Nor Medication Use:
  This value is slightly elevated but not significantly enough to be directly attributed to asthma or medication. It could be situational due to stress or anxiety.

Oxygen Saturation: 88%

• Disease Process:
  The low oxygen saturation is indicative of hypoxemia caused by bronchoconstriction and impaired gas exchange during the asthma attack.