A nurse is providing care for a patient who has recently been admitted to the postsurgical unit from PACU following a transuretheral resection of the prostate
The nurse is aware of the nursing diagnosis of Risk for Imbalanced Fluid Volume. In order to assess for this risk, the nurse should prioritize what action?
A) Closely monitoring the input and output of the bladder irrigation system
B) Administering parenteral nutrition and fluids as ordered
C) Monitoring the patient's level of consciousness and skin turgor
D) Scanning the patient's bladder for retention every 2 hours
Ans: A
Feedback:
Continuous bladder irrigation effectively reduces the risk of clots in the GU tract but also creates a risk for fluid volume excess if it becomes occluded. The nurse must carefully compare input and output, and ensure that these are in balance. Parenteral nutrition is unnecessary after prostate surgery and skin turgor is not an accurate indicator of fluid status. Frequent bladder scanning is not required when a urinary catheter is in situ.
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