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Which nursing diagnosis is priority for the client who has undergone a TURP?
- A. Potential for sexual dysfunction.
- B. Potential for an altered body image.
- C. Potential for chronic infection.
- D. Potential for hemorrhage.
Correct Answer: D
Rationale: Hemorrhage is the priority post-TURP due to the risk of significant bleeding from the surgical site, which can be life-threatening. Sexual dysfunction, body image, and infection are secondary concerns.
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The elderly client presents to the emergency department complaining of burning on urination with an urgency to void, and a temperature of 99.8°F. Which intervention should the nurse implement first?
- A. Ask the client to provide a clean voided midstream urine for culture.
- B. Insert an 18-gauge peripheral IV catheter and start normal saline fluids.
- C. Arrange for the client to be admitted to the medical unit.
- D. Initiate the ordered intravenous antibiotic medication.
Correct Answer: A
Rationale: Burning, urgency, and low-grade fever suggest a UTI. A midstream urine culture is the first step to confirm the diagnosis and guide treatment. IV fluids, admission, or antibiotics follow after diagnostic confirmation.
The client with CKD is placed on a fluid restriction of 1,500 mL/day. On the 7 a.m. to 7 p.m. shift the client drank an eight (8)-ounce cup of coffee, 4 ounces of juice, 12 ounces of tea, and 2 ounces of water with medications. What amount of fluid can the 7 p.m. to 7 a.m. nurse give to the client?
Correct Answer: 720 mL
Rationale: Convert ounces to mL (1 oz ≈ 30 mL): Coffee: 8 oz = 240 mL, Juice: 4 oz = 120 mL, Tea: 12 oz = 360 mL, Water: 2 oz = 60 mL. Total consumed: 240 + 120 + 360 + 60 = 780 mL. Daily limit: 1,500 mL. Remaining: 1,500 - 780 = 720 mL.
When administering the bladder instillation containing the chemotherapeutic drug, which safety precaution is most important for the nurse to take?
- A. Wear two pairs of latex gloves.
- B. As a mass syringe for the drug.
- C. Avoid wearing clothing with long sleeves.
- D. Limit contact time with the client.
Correct Answer: A
Rationale: Wearing two pairs of latex gloves protects the nurse from exposure to the chemotherapeutic drug during instillation.
The client is reporting chills, fever, and left costovertebral pain. Which diagnostic test should the nurse expect the HCP to prescribe first?
- A. A midstream urine for culture.
- B. A sonogram of the kidney.
- C. An intravenous pyelogram for renal calculi.
- D. A CT scan of the kidneys.
Correct Answer: A
Rationale: Chills, fever, and costovertebral pain suggest pyelonephritis. A midstream urine culture is the first test to identify the causative organism. Imaging (sonogram, IVP, CT) is secondary to confirm complications or other diagnoses.
After the TURP, which assessment finding would the nurse expect to observe during the immediate postoperative period?
- A. Light pink to clear urine
- B. Second sediments in urine
- C. Decreased volume of urine
- D. Grossly bloody urine
Correct Answer: D
Rationale: Grossly bloody urine is expected immediately after TURP due to surgical trauma to the prostate.