When assessing a client who had a transurethral resection of the prostate (TURP) one day ago, the nurse observes that his scrotum and penis are edematous. Which intervention(s) should the nurse implement? Select all that apply.

Put a pillow under the buttocks.

Apply a cold pack to the scrotal and penile areas.

Obtain a specimen for urinalysis.

Remove the indwelling urinary catheter.

Notify the healthcare provider immediately.

Answer and Explanation

Correct Answer : B,E

Choice A reason: Elevating the buttocks with a pillow is not specifically indicated in the scenario provided. While it might assist in other situations to reduce swelling by using gravity, it isn't a standard intervention for the described situation post-TURP.

Choice B reason: Applying a cold pack to the scrotal and penile areas can help reduce the swelling and discomfort associated with edema. Cold therapy is effective in constricting blood vessels and reducing inflammation, making it an appropriate immediate intervention.

Choice C reason: While obtaining a urinalysis might provide information on the presence of infection or other abnormalities, it does not directly address the immediate issue of the observed edema. Therefore, it is not a primary intervention in this scenario.

Choice D reason: Removing the indwelling urinary catheter without specific orders can lead to complications and is not advised as an initial intervention. The catheter serves a critical purpose post-surgery and should be handled according to protocol or provider direction.

Choice E reason: Notifying the healthcare provider immediately is crucial when unexpected postoperative complications such as edema occur. Prompt communication allows for timely medical intervention and ensures that the patient receives the necessary care.

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Correct Answer is C

Explanation

Choice A reason: Placing an indwelling urinary catheter and instituting strict intake and output measurements can be done later if needed, but addressing the chest pain is the priority.

Choice B reason: Securing consent for coronary angiography and intervention is important but should be done after addressing the immediate chest pain and potential myocardial infarction.

Choice C reason: Administering aspirin is crucial as it acts as an antiplatelet agent, helping to reduce the risk of further clot formation and improving outcomes in the setting of acute coronary syndrome.

Choice D reason: Evaluating extremities for perfusion is important but secondary to administering aspirin in this acute situation.

A. Washing for a total of 20 seconds. B. Lathering using a circular movement. C. Turning the water off using bare hands. D. Holding hands below elbows when rinsing.

Correct Answer is C

Explanation

Choice A reason: Washing for a total of 20 seconds is correct and meets hand hygiene guidelines.

Choice B reason: Lathering using a circular movement is an appropriate technique for thorough handwashing.

Choice C reason: Turning the water off using bare hands can lead to recontamination of the hands. The UAP should use a paper towel to turn off the faucet.

Choice D reason: Holding hands below elbows when rinsing is correct to allow water to run off the hands and prevent contamination.

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When assessing a client who had a transurethral resection of the prostate (TURP) one day ago, the nurse observes that his scrotum and penis are edematous. Which intervention(s) should the nurse implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?

Correct Answer is C

Explanation

The nurse observes an unlicensed assistive personal (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

Correct Answer is C

Explanation

Which assessment technique provides the most useful data when the nurse is concerned about possible urinary retention?

The nurse is teaching a female client about preventive measures for urinary tract infections (UTI). Which information should the nurse include?

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The nurse knows that a medication has the side effect of orthostatic hypotension. Which assessment should the nurse make before administering the medication?

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