After reviewing the electronic medical record shown in the accompanying figure for a patient who had transurethral resection of the prostate the previous day, which information requires the most rapid action by the nurse?
a. Elevated temperature
b. Respiratory rate and lung sounds
c. Bladder spasms and decreased urine output
d. No prescription for antihypertensive drugs
ANS: C
Bladder spasms and lack of urine output indicate that the nurse needs to assess the continuous bladder irrigation for kinks and may need to manually irrigate the patient's catheter. The other information will also require actions, such as having the patient take deep breaths and cough and discussing the need for antihypertensive medication prescriptions with the health care provider, but the nurse's first action should be to address the problem with the urinary drainage system.
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