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 C
Explanation
Rationale:
A. Placing the client supine with knees bent helps reduce abdominal pressure, but it is not the first action. Protecting the exposed organs from infection or drying out takes priority.
B. Assessing for manifestations of shock is important, but the immediate concern is to prevent further injury or infection to the exposed tissues.
C. The priority action when a wound eviscerates is to cover the area with a sterile dressing moistened with 0.9% sodium chloride solution to keep the organs moist and prevent infection until surgical repair can be done.
D. Raising the head of the bed slightly may help reduce pressure, but it is not the most immediate action compared to covering the exposed organs to prevent drying or infection.
Correct Answer is D
Explanation
Rationale:
A. Cold fluids are less effective in stimulating bowel movements compared to warm fluids. Warm fluids tend to promote peristalsis and help relieve constipation, making cold fluids a less appropriate option.
B. A low-fiber diet would worsen constipation. High-fiber foods are more effective in promoting bowel regularity by adding bulk to the stool, facilitating easier passage.
C. Mineral oil is not a first-line treatment for constipation due to the risk of nutrient malabsorption and potential complications like aspiration in bedridden clients. It should be used cautiously.
D. Increasing fluid intake is an essential intervention for constipation, especially for clients on bedrest. Proper hydration softens stools and helps in promoting bowel movements, reducing the risk of constipation.