A nurse is planning care for a client who is 2 hr postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?
Remind the client he might feel a constant urge to void.
Weigh the client every evening.
Monitor the client's urine output every 6 hr.
Restrict the client's oral fluid intake.
The Correct Answer is A
Rationale:
A. Clients receiving continuous bladder irrigation after a transurethral resection of the prostate (TURP) often feel a constant urge to void due to the presence of the catheter and the irrigation fluid in the bladder. The nurse should reassure the client that this sensation is expected.
B. Weighing the client is not necessary for immediate postoperative care following TURP. Fluid balance is managed by monitoring urine output rather than daily weight.
C. Urine output should be monitored more frequently than every 6 hours in the immediate postoperative period, especially with continuous bladder irrigation, to ensure there are no blockages or complications.
D. Fluid restriction is not recommended after TURP. In fact, encouraging oral fluid intake helps maintain hydration and prevents blood clots in the bladder irrigation system.
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Correct Answer is B
Explanation
Rationale:
A. Assisting the client to the bathroom every 2 hours may not support bladder retraining, which aims to increase the time between voids and encourage the client to recognize the need to urinate.
B. Encouraging the client to hold her urine when feeling the urge is a key component of bladder retraining, as it helps to increase bladder capacity and promotes a normal voiding pattern.
C. Restricting oral fluid intake is not recommended, as it can lead to dehydration and may not effectively aid in bladder retraining. Adequate fluid intake is essential for bladder health.
D. Providing adult diapers does not promote bladder retraining; it may enable continued incontinence rather than encouraging the client to regain control over bladder function.
Correct Answer is D
Explanation
Rationale:
A. Requesting an indwelling urinary catheter is not appropriate for preventing skin breakdown; catheters can increase the risk of urinary tract infections and skin irritation.
B. Cleaning the skin and perineum with hot water can cause irritation and dryness. Instead, using mild soap and warm water is recommended for cleaning.
C. Checking the client's skin every 8 hours may not be frequent enough for a client with incontinence, as more frequent assessments are needed to catch signs of breakdown early.
D. Applying a moisture barrier ointment to the skin protects it from moisture and irritants, helping to prevent skin breakdown in clients with urinary incontinence. This action is proactive and aligns with best practices for skin care.