A patient had a transurethral resection of the prostate (TURP), and the urine in the urinary irrigation drainage bag is very dark red
Which nursing actions should be included in his plan of care? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Check for catheter occlusion.
2. Increase the flow rate of irrigant solution.
3. Check vital signs.
4. Ask the patient to drink more fluids.
5. Assess the patient for hyponatremia.
1,2
Rationale 1: Following prostatectomy, urine should appear light pink to clear with an occasional blood clot. Urine that is very dark red may indicate increased venous bleeding or inadequate urine dilution. The catheter may be occluded and should be checked first.
Rationale 2: Increasing the flow rate of irrigant should assist in making the urine clear. If the urine does not clear, the nurse should notify the physician.
Rationale 3: Checking vital signs is important but not specific to this situation.
Rationale 4: Asking the patient to increase fluid intake may increase urine output and assist in diluting the urine, but this may take several hours.
Rationale 5: Assessing for hyponatremia is a nursing action to detect absorption of bladder irrigation solution.
You might also like to view...
A postoperative client is moving from the bed to a chair when blood drips from the dressing. The nurse assesses the incision and notes evisceration. What does the nurse do first?
A) Place a dry, sterile dressing over the protruding organs. B) Place a pressure dressing over the opening and secure. C) Have the client lay quietly on back and call the physician. D) Moisten sterile gauze with normal saline and place on any organ.
Postoperative care for a woman following a mastectomy will include arm exercises to:
A) promote drainage after lymphatic disruption. B) decrease pain as the surgical site heals. C) strengthen the affected muscles. D) increase firmness in the remaining breast tissue.
Which of the following statements made by a nurse caring for a client reporting severe pain ex-presses the most insight into how pain impacts a client's energy reserves?
1. "If I can't get his pain under control, his recovery will take a lot longer." 2. "Pain certainly interferes with the client's ability to rest and recuperate." 3. "I'm going to call for another pain prescription so he can get some rest." 4. "Trying to cope with pain is using up the energy that his recovery requires."
The client is taking risperidone (Risperdal) to treat the positive and negative symptoms of schizophrenia. Improvement of which of the following negative symptoms indicate the drug is effective?
a) Abnormal thought form. b) Hallucinations and delusions. c) Bizarre behavior. d) Asocial behavior and anergia.