The nurse cares for a client six hours post-operative following a transurethral resection of a prostate (TURP).
The client is demonstrating signs and symptoms of ?
urinary catheter obstruction
shock
hyponatremia
urinary tract infection
The Correct Answer is A
Choice A rationale: The signs and symptoms of urinary catheter obstruction include hematuria with clots, bladder spasms, and a feeling of urinary urgency. The nurse should increase the rate of the continuous bladder irrigation to flush out the clots and relieve the obstruction. The nurse should also monitor the client's vital signs, fluid balance, and pain level. The other options are not consistent with the client's presentation.
Choice B rationale: Shock would cause hypotension, tachycardia, and decreased urine output.
Choice C rationale: Hyponatremia would cause confusion, weakness, and seizures.
Choice D rationale: Urinary tract infection would cause fever, chills, and foul-smelling urine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Cellulitis management typically involves wound care, antibiotics, and monitoring. It's a suitable assignment for a new graduate nurse to begin learning about wound management and diabetic care.
Choice B rationale: Post-operative care for an amputation requires experience in assessing and managing post-surgical complications, which might not be suitable for a new graduate nurse.
Choice C rationale: Diabetic ketoacidosis management involves complex insulin therapy and critical care, which might be overwhelming for a new graduate nurse.
Choice D rationale: While hyperglycemia requires monitoring and intervention, the cause and severity need to be determined before assigning this patient to a new
graduate nurse.
Correct Answer is C
Explanation
Choice A rationale: A client with nausea, vomiting, and abdominal pain may have gastroenteritis, food poisoning, or appendicitis, which are not directly related to the eyes.
Choice B rationale: A client with chest tightness and heartburn may have gastroesophageal reflux disease (GERD), angina, or myocardial infarction (MI), which are also not associated with the eyes.
Choice C rationale: A client with facial drooping and left-sided weakness may have a stroke, which is a medical emergency that requires immediate attention. An eye examination can help detect signs of stroke, such as pupil asymmetry, visual field defects, or eye movement abnormalities. A stroke can cause permanent brain damage or death if not treated promptly.
Choice D rationale: A client with fatigue, fever, and productive cough may have a respiratory infection, such as pneumonia or tuberculosis, which are unlikely to affect the eyes unless there is a systemic complication.
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