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.
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. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Constant erythema and warmth are more characteristic of venous insufficiency or inflammation, rather than peripheral artery disease. PAD is associated with reduced blood flow and tissue perfusion, leading to symptoms like pallor, coolness, and pain rather than persistent redness and warmth in affected areas.
Choice B rationale
Elevating the legs worsens ischemic pain in PAD by further reducing blood flow. Symptoms typically improve when the legs are in a dependent position due to gravity aiding perfusion. This is a key distinguishing feature in PAD compared to other vascular conditions like venous insufficiency.
Choice C rationale
Discomfort in the legs during exercise relieved by rest, known as intermittent claudication, is a hallmark of PAD. It occurs due to inadequate blood supply during increased activity. Rest restores perfusion and alleviates ischemic pain. This symptom reflects underlying arterial obstruction, a core pathophysiological feature of PAD.
Choice D rationale
Peripheral pulses in PAD are diminished or absent due to arterial obstruction. Bounding pulses in dependent positions suggest venous issues or high cardiac output, not arterial insufficiency. Accurate pulse assessment helps differentiate PAD from other vascular conditions. Normal pulse documentation is critical to diagnosis.
Correct Answer is D
Explanation
Choice A rationale
Amlodipine, a calcium channel blocker, primarily acts on vascular smooth muscles to reduce blood pressure. It does not directly affect renal function or significantly increase urine output. This statement reflects a misunderstanding of the drug's mechanism of action.
Choice B rationale
Edema, a common side effect of amlodipine, is due to vasodilation and capillary leakage, particularly in lower extremities. However, sudden discontinuation of the medication may lead to rebound hypertension and should be avoided. Reporting side effects is crucial for alternative management.
Choice C rationale
Amlodipine does not necessitate routine potassium monitoring as it does not significantly affect potassium homeostasis. This requirement is more commonly associated with potassium-wasting diuretics or renin-angiotensin-aldosterone system modulators.
Choice D rationale
Constipation and abdominal pain, although less common, may occur due to gastrointestinal motility changes caused by smooth muscle relaxation. Prompt reporting ensures timely assessment and potential treatment modifications to enhance adherence.
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