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

Right-sided heart failure with thickened heart muscle refers specifically to the impaired filling capacity due to diastolic dysfunction. Diastolic dysfunction affects the filling phase, not the pumping phase. It may involve one side or both sides but is not explicitly described as right and left-sided diastolic in this context.

Choice B rationale

Right-sided systolic heart failure affects the pumping ability, while diastolic affects filling. Both conditions together do not explain the thickened myocardium impairing filling. A combination of systolic and diastolic failure typically includes both pumping and filling abnormalities rather than isolated thickening with poor filling.

Choice C rationale

Right-sided diastolic failure results from impaired ventricular relaxation and thickened myocardium, leading to reduced filling capacity. This type of failure involves the heart's inability to accommodate blood during diastole, consistent with the description of thickened heart muscle and poor filling on the right side.

Choice D rationale

Right-sided systolic failure involves impaired contractility and pumping of blood to the lungs, not poor filling caused by thickened muscle. Systolic dysfunction decreases the heart's output rather than affecting the filling phase described in this scenario.

Choice A rationale

Referring the client to see an optometrist is inappropriate because visual disturbances can be a sign of digoxin toxicity, which requires immediate medical attention rather than routine visual examination. Toxicity manifests due to elevated serum digoxin levels, with symptoms including blurred vision and yellow-green halos. Normal digoxin range is 0.5-2.0 ng/mL.

Choice B rationale

Asking if the client wears glasses or contact lenses does not address the root cause of visual disturbances, which is likely linked to digoxin toxicity. Such queries delay prompt medical intervention needed to evaluate and manage the client’s condition. Ocular aids are unrelated to pharmacological adverse effects.

Choice C rationale

Obtaining a prescription for stat laboratory tests is essential for assessing serum digoxin levels and electrolytes, particularly potassium, as hypokalemia increases sensitivity to digoxin toxicity. Prompt identification of toxicity allows timely interventions, including discontinuation of digoxin or administration of antidotes like Digibind.

Choice D rationale

Obtaining the client’s blood pressure is irrelevant in this scenario, as visual disturbances are not indicative of blood pressure abnormalities but rather digoxin toxicity. Immediate focus should be on confirming and managing toxicity through laboratory evaluation and clinical assessment.