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 A

Explanation

Choice A rationale

Stones lodged in the ureter cause severe, colicky pain due to intense peristaltic waves attempting to dislodge the obstruction. The pain often radiates down the thigh and groin as the ureter's path follows these areas. Additionally, urinary retention or frequent urges with minimal voiding occurs due to irritation and partial blockage, confirming ureteral stone involvement.

Choice B rationale

While some stones may pass spontaneously, timing varies widely depending on size, location, and hydration levels. Pain and obstruction may persist longer than a few hours, making this statement misleading without further assessment.

Choice C rationale

Bladder stones may cause lower abdominal pain, frequency, and hematuria but do not typically involve radiating pain to the groin or thigh. The described symptoms strongly suggest ureteral obstruction rather than bladder involvement.

Choice D rationale

While procedural removal is an option for large or immovable stones, initial approaches often include pain control, hydration, and medical expulsive therapy. Surgical intervention is not the first-line explanation unless conservative management fails.

A. Magnesium and bilateral lower extremity ultrasounds. B. Urinalysis, blood chemistry, and 12-lead electrocardiogram. C. Complete blood count and electroencephalogram. D. Troponin, calcium, and partial thromboplastin time.

Correct Answer is B

Explanation

Choice A rationale

Magnesium levels and bilateral lower extremity ultrasounds are not specific for assessing target organ damage in hypertension. While magnesium may influence cardiovascular health, it is not a primary indicator of organ damage. Ultrasounds evaluate arterial or venous abnormalities, not hypertension’s systemic effects.

Choice B rationale

Urinalysis, blood chemistry, and a 12-lead electrocardiogram assess renal, metabolic, and cardiac effects of hypertension. Proteinuria in urinalysis indicates kidney damage. Electrolyte imbalances or creatinine elevations suggest renal impairment. An ECG reveals left ventricular hypertrophy or ischemia. These tests comprehensively evaluate hypertension-related complications.

Choice C rationale

A complete blood count evaluates blood cell counts but does not directly assess target organ damage from hypertension. An electroencephalogram assesses brain activity, not hypertension-induced injury. These tests are inappropriate for this diagnostic goal.

Choice D rationale

Troponin, calcium, and partial thromboplastin time evaluate myocardial infarction, bone health, and coagulation, respectively. They do not provide information about hypertension’s systemic organ effects. Accurate test selection ensures appropriate diagnostic focus.

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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?