A client is receiving care on an inpatient urology unit 24 hours after undergoing a transu… — NCLEX-PN

A client is receiving care on an inpatient urology unit $24$ hours after undergoing a transurethral resection of the prostate (TURP) with continuous bladder irrigation. The practical nurse (PN) evaluates the client's status during the current shift. Which of the following findings are correct indicators of complications that require immediate escalation to the registered nurse? (Select all that apply.)

A serum sodium laboratory result of $124 \text{ mEq/L}$ Answer
A resting heart rate of $118$ beats per minute with a blood pressure of $92/54 \text{ mm Hg}$ Answer
A sudden change in the urinary drainage color to thick, bright red with large clotsAnswer
D
A hemoglobin laboratory result of $13.8 \text{ g/dL}$
E
A continuous return of light pink fluid in the urinary catheter drainage bag
F
A client statement describing intermittent bladder spasm pain rated as $4$ on a $0$ to $10$ scale

Answer

The clinical indicators requiring immediate escalation are the critically low serum sodium level, the borderline shock vital signs (tachycardia and hypotension), and the sudden presence of bright red drainage with large clots.

Following a transurethral resection of the prostate (TURP), recognizing severe complications is critical to reducing client risk. A serum sodium level of

124 \text{ mEq/L}

is dangerously low and indicates TURP syndrome, a complication caused by intravascular absorption of irrigation fluid. A resting heart rate of

118

beats per minute combined with a blood pressure of

92/54 \text{ mm Hg}

points directly to early hypovolemic shock. Additionally, thick, bright red urinary drainage with large clots signifies active arterial bleeding, which is a medical emergency. All three of these findings require immediate escalation to the registered nurse for urgent intervention.

Step-by-Step Solution

Analyze the surgical procedure to identify high-risk complications.

A TURP procedure carries a high risk for hemorrhage and TURP syndrome (dilutional hyponatremia due to irrigation fluid absorption).

Identifying procedure-specific risks guides targeted data collection and sets the threshold for clinical escalation.

Evaluate the laboratory results against expected physiological parameters.

The sodium level of

124 \text{ mEq/L}

is critically low, while the hemoglobin of

13.8 \text{ g/dL}

is normal.

Severe hyponatremia is the hallmark of TURP syndrome, which can rapidly lead to cerebral edema, seizures, and death if not urgently treated.

Assess the vital signs and drainage characteristics for signs of instability.

The combination of tachycardia (

118

beats per minute) and hypotension (

92/54 \text{ mm Hg}

), along with bright red arterial bleeding, indicates impending hemorrhagic shock.

Prompt escalation to the RN is required to stabilize the client's airway, breathing, and circulation (ABCs) before cardiopulmonary collapse occurs.

Key Concept

Reduction of risk potential following a transurethral resection of the prostate (TURP) requires identifying early indicators of life-threatening complications, specifically hemorrhagic shock and TURP syndrome.

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