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

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.

A. I will decrease my caffeine intake down to one cup per day. B. I should drink grapefruit juice instead of orange juice in the morning. C. I will practice Kegel exercises regularly. D. I should have a fixed time schedule for going to the bathroom.

Correct Answer is B

Explanation

Choice A rationale

Reducing caffeine consumption decreases bladder irritation and helps manage urinary incontinence symptoms. Caffeine stimulates bladder activity and exacerbates urgency and frequency. Clinical evidence supports its reduction as part of an effective urinary incontinence management strategy.

Choice B rationale

Grapefruit juice is acidic and irritates the bladder lining, worsening symptoms of urinary incontinence. Substituting orange juice with grapefruit juice does not mitigate bladder irritation. Both contain acids and should be avoided to manage urinary incontinence effectively. Citrus juices are contraindicated in clients managing urinary incontinence.

Choice C rationale

Kegel exercises improve pelvic floor muscle strength, reducing urinary incontinence episodes. They enhance the function of the urinary sphincter and support better bladder control. Kegel exercises are widely recommended in clinical practice for patients managing urinary incontinence and are supported by robust scientific evidence.

Choice D rationale

Scheduled bathroom visits prevent bladder overdistension and manage urinary incontinence symptoms effectively. Timed voiding trains the bladder to hold urine for specific periods, reducing the frequency of urgency episodes. It is an effective behavioral approach supported by clinical guidelines for managing urinary incontinence.

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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?