Nokea
The client is eight (8) hours post-transurethral prostatectomy for cancer of the prostate. Which nursing intervention is priority at this time?
- A. Control postoperative pain.
- B. Assess abdominal dressing.
- C. Encourage early ambulation to prevent DVT.
- D. Monitor fluid and electrolyte balance.
Correct Answer: D
Rationale: Fluid and electrolyte balance is critical post-TURP due to irrigation and bleeding risks (e.g., hyponatremia). Pain, dressings, and ambulation are important but secondary.
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Which question is most important for the nurse to ask next?
- A. Have you ever had any menstrual periods?
- B. Do you have any pubic hair growth?
- C. Have you ever been sexually attracted to males?
- D. Are there any siblings with a similar problem?
Correct Answer: A
Rationale: Determining if the client has ever menstruated is critical to differentiate between primary amenorrhea (never menstruated) and secondary amenorrhea (cessation of periods), guiding further assessment.
When the client asks how this condition will affect him sexually, which response by the nurse is most appropriate?
- A. It most likely will have little effect on your masculinity.
- B. It means that you will probably be impotent.
- C. You may notice that your breasts will enlarge later.
- D. Your sex drive will not be like that of other boys.
Correct Answer: A
Rationale: An undescended testicle, if corrected, typically has minimal impact on sexual function or masculinity, especially if addressed early.
The nurse correctly teaches a couple that immediately after a vasectomy, it is best to continue using an alternative birth control method for which time period?
- A. 1 month
- B. 6 weeks
- C. 12 weeks
- D. 6 months
Correct Answer: C
Rationale: Sperm may remain in the vas deferens for up to 12 weeks post-vasectomy, requiring alternative contraception until azoospermia is confirmed.
The client is diagnosed with a rectovaginal fistula which is to be managed medically. Which information should the nurse teach the client prior to discharge?
- A. Douche with normal saline.
- B. Eat a low-residue diet.
- C. Keep ice packs to the area.
- D. Use an abdominal binder.
Correct Answer: B
Rationale: A low-residue diet reduces fecal output, aiding healing of a rectovaginal fistula. Douching risks infection, ice packs are ineffective, and binders are unrelated.
Unless the physician specifies otherwise, what is the maximum volume of urine the nurse should remove with the catheter at this time?
- A. 500 mL
- B. 1,000 mL
- C. 1,500 mL
- D. 2,000 mL
Correct Answer: B
Rationale: Removing up to 1,000 mL prevents bladder decompression injury, balancing the need to relieve retention with the risk of hypotension or hematuria.