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?

Assess for hypotension.

Assess for distention above the pubis area.

Monitor the client's laboratory values for hypernatremia.

Maintain strict intake and output records.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Hypotension is not a typical sign of fluid overload. Fluid overload often presents with hypertension due to increased circulatory volume. Monitoring blood pressure is essential, but hypotension does not reliably indicate fluid overload. This option does not align with scientific understanding of fluid overload symptoms.

Choice B rationale

Distention above the pubis area suggests urinary retention or bladder distension rather than fluid overload. While important to assess, it does not directly indicate fluid overload. This symptom is more related to mechanical issues than systemic fluid imbalance and volume overload.

Choice C rationale

Hypernatremia is not a sign of fluid overload. Fluid overload typically results in dilutional hyponatremia, where excessive fluids lower sodium levels. Monitoring sodium levels is useful, but hypernatremia would suggest dehydration or other conditions, not excess fluid volume. This choice is inconsistent with scientific knowledge.

Choice D rationale

Maintaining strict intake and output records is a fundamental approach to monitoring fluid balance. Accurate measurements of fluid intake and output help detect fluid overload early. This method directly correlates with assessing excess fluid volume in clinical practice. It is a reliable, evidence-based intervention for monitoring fluid status. .

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Correct Answer is B

Explanation

Choice A rationale

Edema of the lower extremities suggests right-sided heart failure, not left ventricular failure. Fluid backs up into systemic circulation in right-sided failure, while left-sided failure primarily affects pulmonary circulation. Differentiating between these conditions is essential for targeted management.

Choice B rationale

Pulmonary crackles result from fluid accumulation in alveoli due to left ventricular failure, where decreased cardiac output causes blood to back up into pulmonary vasculature. Crackles indicate pulmonary congestion or edema. Prompt identification aids in early intervention. Normal respiratory assessment excludes crackles.

Choice C rationale

Ascites is more indicative of chronic right-sided heart failure or liver disease, not acute left ventricular failure. Ascites results from systemic venous congestion, which is less common in isolated left-sided heart failure. Differentiating causes helps refine diagnostic focus.

Choice D rationale

Jugular vein distention is associated with elevated central venous pressure, typical of right-sided heart failure or combined heart failure. It does not specifically characterize left ventricular failure. Accurate recognition of findings ensures precise diagnosis and management.

A. Corticosteroid. B. Diphenhydramine. C. Desmopressin (DDAVP). D. Hydrochlorothiazide (HCTZ). . .

Correct Answer is A

Explanation

Choice A rationale

Corticosteroids are the mainstay of treatment for thrombocytopenia, particularly immune-mediated types like ITP. They work by suppressing immune-mediated platelet destruction, thereby increasing platelet counts and improving symptoms effectively.

Choice B rationale

Diphenhydramine, an antihistamine, may be used for allergic reactions but has no role in treating thrombocytopenia. It does not address immune-mediated mechanisms or platelet destruction directly.

Choice C rationale

Desmopressin (DDAVP) increases von Willebrand factor and Factor VIII activity, making it appropriate for certain clotting disorders but irrelevant for thrombocytopenia, as it does not restore platelet numbers or function.

Choice D rationale

Hydrochlorothiazide, a diuretic, is used for hypertension or fluid management but has no therapeutic effect on platelet counts or immune-mediated mechanisms in thrombocytopenia. Its use is unrelated to the described condition. .

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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?

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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?