The nurse is providing education to a client who is returning home with an indwelling urinary catheter after having a transurethral resection of the prostate (TURP). Which statement made by the client demonstrates a need for the nurse to clarify the instructions?

Start pelvic floor exercises.

Report fever or chills.

Increase fluid intake to help with hydration.

Tape urinary catheter securely to the thigh.

Answer and Explanation

The Correct Answer is A

Choice A reason: Starting pelvic floor exercises might be beneficial in the long term for improving urinary control after TURP. However, immediately following the surgery and while the indwelling catheter is in place, it may not be the appropriate time to begin these exercises. The nurse should clarify when and how to start pelvic floor exercises.

Choice B reason: Reporting fever or chills is crucial because these symptoms could indicate an infection, which requires prompt medical attention. This statement reflects an understanding of important post-operative care instructions and does not need clarification.

Choice C reason: Increasing fluid intake to help with hydration is important for clients with a urinary catheter. Adequate hydration helps flush the urinary system and prevent complications such as urinary tract infections. This statement does not need clarification.

Choice D reason: Taping the urinary catheter securely to the thigh helps prevent tension on the catheter and reduces the risk of accidental dislodgement or trauma. This instruction is correct and does not need clarification.

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Correct Answer is A

Explanation

Choice A reason: Administering IV furosemide (a diuretic) is crucial for managing the client's symptoms of fluid overload, as indicated by enema and elevated brain natriuretic peptide (BNP) levels. Furosemide helps reduce the volume of fluid in the body, relieving symptoms of heart failure and improving breathing. It addresses the most urgent need for the client.

Choice B reason: Inserting an indwelling urinary catheter might be necessary for accurate measurement of urine output, especially in a client receiving diuretic therapy. However, it is not the most immediate intervention needed to stabilize the client's condition.

Choice C reason: Monitoring for telemetry ST segment changes is important for clients with cardiac conditions. While it is necessary for ongoing assessment, it does not address the immediate need to relieve fluid overload and improve the client's respiratory status.

Choice D reason: Giving a bronchodilator per inhaler can help with respiratory symptoms related to emphysema. However, in this scenario, the primary issue is fluid overload due to heart failure, which needs to be addressed first with diuretic therapy.

A. Lung sounds. B. Turgor. C. Weight. D. Blood pressure. H. Here's the edited text with the instructions applied:

Correct Answer is C

Explanation

Choice A reason: Lung sounds are important to assess for signs of fluid in the lungs, such as crackles, which can occur with fluid volume overload. However, they do not directly measure fluid balance.

Choice B reason: Turgor assesses skin elasticity and hydration status, but it is not the most accurate indicator of overall fluid balance in the context of fluid volume overload.

Choice C reason: Weight is the most accurate and direct measure of fluid balance. Daily weight monitoring can track changes in fluid status, as weight fluctuations can reflect gains or losses in body fluid.

Choice D reason: Blood pressure is important to monitor, especially in clients with fluid volume issues, but it is not the most direct measure of fluid balance. Weight changes provide more precise information about fluid status.

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The nurse is providing education to a client who is returning home with an indwelling urinary catheter after having a transurethral resection of the prostate (TURP). Which statement made by the client demonstrates a need for the nurse to clarify the instructions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of emphysema and heart failure is admitted to the emergency department with enema, coughing, and shortness of breath. The client's laboratory value for brain natriuretic peptide is elevated. Which prescription is most important for the nurse to implement?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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