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 C

Explanation

Choice A rationale

Metal catheters with prostatic curves are used in challenging cases of urinary retention caused by BPH. However, these catheters are not the first-line intervention due to their specialized nature and the risk of injury. Less invasive measures should be tried first.

Choice B rationale

Cystostomy, a surgical procedure that creates a suprapubic urinary drainage site, is reserved for severe cases of urinary retention where catheterization fails. It is not the initial step due to its invasive nature and requirement for surgical expertise.

Choice C rationale

Inserting an indwelling urethral catheter is the first-line action for managing acute urinary retention associated with BPH. It provides immediate bladder decompression, relieves discomfort, and reduces risks of complications like hydronephrosis or bladder rupture.

Choice D rationale

Discussing surgical options addresses the long-term management of BPH but does not resolve acute urinary retention. Interventions like catheterization should first alleviate symptoms before evaluating the need for definitive surgical treatment. .

A. Medications. B. Negative-pressure devices. C. Penile injections. D. Penis transplant.

Correct Answer is A

Explanation

Choice A rationale

Medications, such as phosphodiesterase type-5 inhibitors (e.g., sildenafil), are typically the next line of treatment for erectile dysfunction (ED) after lifestyle modifications fail. These agents enhance blood flow to the penile tissues during sexual stimulation by inhibiting the breakdown of cyclic guanosine monophosphate, facilitating erectile function.

Choice B rationale

Negative-pressure devices, also known as vacuum erection devices, are considered third-line treatments and are typically used in clients for whom oral medications are contraindicated or have failed. These devices work by mechanically increasing blood flow to the penis but are less effective than pharmacological interventions.

Choice C rationale

Penile injections, such as alprostadil, are invasive and used as a later option when oral medications and devices are unsuccessful or contraindicated. These injections directly relax the smooth muscle to increase penile blood flow, but they are generally not first-line treatments.

Choice D rationale

Penis transplants are experimental and not recognized as a standard treatment for erectile dysfunction. This option is far from practical or feasible and is considered unsuitable for most clients, especially given the complexity of the 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?