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 D
Explanation
Rationale:
A. Adequate nutrition actually promotes wound healing. Poor nutrition, especially a lack of protein and vitamins, delays healing and increases the risk of infection.
B. Chronic wounds heal better in a moist environment rather than a dry one. Moist wound healing promotes cell migration and prevents scab formation, improving healing.
C. Fat tissue does not heal more rapidly. In fact, it heals more slowly due to decreased vascularization, which impairs oxygen delivery and nutrient supply to the tissue.
D. Long-term steroid use diminishes the body’s inflammatory response, reducing the body's ability to initiate the healing process. This delay in inflammation can lead to slower wound healing and a higher risk of infection.
Correct Answer is B
Explanation
Rationale:
A. Stating that the phase cannot be determined is incorrect because the wound presents clear signs indicative of a healing phase.
B. The inflammatory phase of healing typically lasts for 3 to 5 days post-injury and is characterized by redness, swelling, warmth, and pain due to the body’s response to injury. The lack of slough or drainage, along with surrounding tissue swelling and pain, aligns with the inflammatory phase.
C. The proliferative phase follows the inflammatory phase and involves the formation of new tissue and the development of granulation tissue, which is not yet apparent in Mr. Jones's wound.
D. The maturation phase occurs after the proliferative phase, focusing on the strengthening and reorganization of collagen, which is not relevant as the wound is still in the inflammatory stage.