Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an indwelling urinary catheter. Which instruction is most important for the nurse to include in the discharge teaching plan?

Avoid driving a car for 2 weeks.

Drink 3 liters of water each day.

Eliminate all spicy foods from your diet.

Clamp the catheter when taking a shower.

Answer and Explanation

The Correct Answer is B

Choice A reason: Avoiding driving is important but not the most critical instruction.

Choice B reason:

The correct answer is b) because drinking plenty of water helps flush the bladder, reduce the risk of infection, and prevent blood clots.

Choice C reason: Eliminating spicy foods may help with overall comfort but is not as important as maintaining proper hydration.

Choice D reason: Clamping the catheter during a shower is not necessary and could cause complications.

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Correct Answer is D

Explanation

Choice A reason: Providing additional oral fluids is not appropriate for SIADH and can worsen fluid retention.

Choice B reason: Measuring glucose levels is important for diabetes management but not directly related to SIADH.

Choice C reason: Using hard candy may help relieve thirst but does not address the underlying issue of fluid retention in SIADH.

Choice D reason:

The correct answer is d) because withholding diuretics and contacting the healthcare provider is necessary to manage the fluid balance in clients with SIADH.

A. Hypotension and venous pooling in the extremities. B. Pain and a burning sensation upon urination and hematuria. C. Profuse diaphoresis and severe, pounding headache. D. Reports of chest pain and shortness of breath.

Correct Answer is C

Explanation

Choice A reason: Hypotension and venous pooling in the extremities are not typical of autonomic dysreflexia. Autonomic dysreflexia usually results in hypertension due to an exaggerated autonomic response to a stimulus such as a full bladder. This condition is characterized by severe, uncontrolled hypertension rather than hypotension.

Choice B reason: While pain and a burning sensation upon urination and hematuria can be related to a urinary tract infection or bladder issue, they are not specific to autonomic dysreflexia. Autonomic dysreflexia presents with symptoms that result from the body's exaggerated response to the stimulus, such as severe headache and sweating.

Choice C reason:

The correct answer is c) because profuse diaphoresis (sweating) and a severe, pounding headache are hallmark signs of autonomic dysreflexia. This condition occurs in individuals with spinal cord injuries at or above the T6 level and is triggered by stimuli like a full bladder, causing a dangerous rise in blood pressure and severe autonomic responses.

Choice D reason: Reports of chest pain and shortness of breath are not typical signs of autonomic dysreflexia. While these symptoms may be concerning, they are not the primary indicators of this specific condition. The severe headache and sweating are more indicative of autonomic dysreflexia.

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Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an indwelling urinary catheter. Which instruction is most important for the nurse to include in the discharge teaching plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with chronic syndrome of inappropriate antidiuretic hormone (SIADH) reports to the nurse of being constantly thirsty. Which action should the nurse take?

Correct Answer is D

Explanation

A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?

Correct Answer is C

Explanation

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