The nurse is providing postoperative care for a male client who had a transurethral resection of the prostate (TURP) 4 hours ago and has continuous irrigation.
Which of the following actions should the nurse take to monitor the client for fluid overload?

Choice A rationale

Decreasing caffeine intake is a proven method for managing urinary incontinence. Caffeine stimulates bladder activity, potentially worsening symptoms. Reducing caffeine to one cup per day can decrease urgency and frequency. This recommendation aligns with the scientific understanding that caffeine is a bladder irritant and is supported by clinical guidelines on managing urinary incontinence.

Choice B rationale

Grapefruit juice is acidic and can irritate the bladder lining, worsening urinary incontinence symptoms. Substituting orange juice with grapefruit juice does not address the problem, as both are acidic and contain bladder irritants. Citrus juices, including grapefruit and orange, are often advised against for patients managing urinary incontinence due to their potential to exacerbate symptoms.

Choice C rationale

Kegel exercises strengthen the pelvic floor muscles, enhancing bladder control and reducing incontinence episodes. This evidence-based practice is recommended for individuals with urinary incontinence. Regular Kegel exercise improves urinary sphincter function and supports the overall health of pelvic muscles, which is key for managing incontinence.

Choice D rationale

Establishing a fixed schedule for bathroom visits can prevent overdistension of the bladder and manage symptoms of urinary incontinence effectively. Timed voiding helps train the bladder and reduce episodes of urgency or leakage. It is widely supported as part of behavioral therapy for urinary incontinence management.

Choice A rationale

Magnesium and bilateral lower extremity ultrasounds are not primary diagnostic tests for hypertension-related target organ damage. Magnesium levels do not directly correlate with hypertension complications, and lower extremity ultrasounds mainly evaluate vascular issues, such as deep vein thrombosis, rather than organs affected by chronic hypertension.

Choice B rationale

Urinalysis assesses kidney function by detecting proteinuria, an indicator of renal damage due to hypertension. Blood chemistry provides electrolytes and renal function metrics, like creatinine (normal range: 0.6–1.2 mg/dL). A 12-lead ECG identifies left ventricular hypertrophy or arrhythmias linked to cardiac strain from persistent high blood pressure, a common sign of target organ damage.

Choice C rationale

Complete blood count evaluates overall health but does not specifically target organ damage related to hypertension. Electroencephalogram measures brain activity and is more relevant for neurological conditions, such as seizures, not complications from high blood pressure.

Choice D rationale

Troponin evaluates myocardial injury in acute settings like myocardial infarction, unrelated to chronic hypertension-induced organ damage. Calcium levels and partial thromboplastin time assess coagulation and bone health but do not directly indicate target organ involvement in hypertension.