The nurse is assessing a client who has undergone a transurethral resection of the prostate (TURP). Which assessment finding requires immediate action by the nurse?
a. Passing small blood clots after catheter removal
b. Experiencing urinary frequency after ca-theter removal
c. Having bright red drainage with multiple blood clots
d. Having the urge to void continuously while the catheter is inserted
C
A client who undergoes a TURP is at risk for bleeding during the first 24 hours after surgery. Passage of small blood clots and tissue debris, urinary frequency and leakage, and the urge to void continuously while the client still has the catheter inserted are all considered to be expected complications of the procedure. They will resolve as the client continues to recover and the ca-theter is removed. However, the presence of bright red blood with clots indicates arterial bleed-ing and should be reported to the provider.
You might also like to view...
A 72-year-old man is newly diagnosed with Alzheimer's disease. The patient's daughter asks the nurse how her father's medication is going to help him. What will the nurse explain in layman's terms?
A) "The drugs work by increasing acetylcholine (ACh) levels in the brain and slowing the progression of the disease." B) "The drugs work by crossing the blood–brain barrier and cure the disease in the brain." C) "The drugs work by increasing ACh levels in the brain and reverse the progression of the disease." D) "The drugs work by crossing the blood–brain barrier and decreasing ACh levels in the neuromuscular junctions."
When planning care for a patient with esophageal varices, which action would be a priority for the nurse?
A) Discussing the importance of Alcoholics Anonymous meetings B) Assessing for signs and symptoms of hemorrhage C) Teaching the patient signs of bleeding to report D) Encouraging rest periods to reduce fatigue
You have been consistently caring for a patient who is suicidal, but who now tells you, "Nurse, I finally have it all figured out. It's going to be just fine." Your best response to this patient is:
A) "I'm so glad to hear that!" B) "What a relief for you!" C) "I'm not sure I understand what you mean. Tell me more." D) "You have an excellent doctor. I knew things would work out in the end!"
An adolescent client complains that the medication makes her feel "lazy". The nurse updates the nursing care plan to include activity intolerance
Which of the following interventions would be most effective in encouraging the client to participate in physical activities during inpatient psychiatric hospitalization? A) Design team games such as volleyball. B) Encourage keeping a diary or log about energy levels. C) Plan weekly individual physical activities. D) Encourage the client to exercise alone.