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

Improved tolerance for daily activities suggests increased energy levels and improved oxygen delivery to tissues, both indicative of effective iron deficiency anemia treatment. Normal hemoglobin levels are 12-16 g/dL for females and 14-18 g/dL for males, supporting enhanced activity tolerance.

Choice B rationale

Decreased paresthesia indicates improved nerve function but is not directly linked to iron deficiency anemia treatment outcomes. Iron deficiency primarily impacts oxygen transport, and improvements in energy levels and activity tolerance are better indicators of therapeutic success.

Choice C rationale

Improved white blood cell count suggests better immune function but does not directly assess anemia treatment efficacy. Iron therapy aims to normalize hemoglobin and hematocrit levels rather than leukocyte parameters, which are unrelated to anemia management.

Choice D rationale

Enhanced balance may indicate improved neuromuscular function but is not directly correlated with anemia treatment. Balance is influenced by multiple factors, including neurological or musculoskeletal health, rather than oxygenation improvements specific to anemia.

A. Explain that the client should return in one month to be reevaluated. B. Assess the client's adherence to lifestyle modifications and medication therapy. C. Explain to the client that the health care provider will increase the dose of one of the medications already prescribed. D. Discuss adding a prescribed calcium-channel blocker to the client's medication regimen.

Correct Answer is B

Explanation

Choice A rationale

Waiting one month before reevaluating blood pressure may overlook potential adherence issues or medication effects. Hypertension requires timely intervention because consistently high values can lead to complications such as stroke or heart attack. The readings of 145/92 mm Hg and 150/89 mm Hg are above the normal range (<120/80 mm Hg), necessitating immediate review of possible contributing factors rather than postponing evaluation.

Choice B rationale

Adherence to lifestyle modifications and prescribed therapies directly affects blood pressure control. Factors such as diet, exercise, and medication compliance significantly influence systolic and diastolic values. Poor adherence can lead to inadequate control of hypertension, which is evident in the readings of 145/92 mm Hg and 150/89 mm Hg. Exploring adherence helps identify reasons for high readings and can guide targeted interventions.

Choice C rationale

Increasing medication dosage without first reviewing adherence overlooks potential causes of suboptimal control such as missed doses, incorrect timing, or lifestyle factors. Adjusting doses may lead to overtreatment, causing complications like hypotension. Addressing adherence first ensures interventions are appropriate and prevents unnecessary medication changes.

Choice D rationale

Adding a calcium-channel blocker involves modifying therapy without investigating adherence to current medications and lifestyle changes. Such an approach risks complicating the treatment plan unnecessarily. It is scientifically prudent to first evaluate the effectiveness of existing treatments through adherence assessments, ensuring interventions are tailored to the individual's needs.

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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?

Nursing Test Bank

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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?

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?