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Soru

Zorluk: ZorReduction of Risk Potential

A practical nurse is collecting data from a client who is 6 hours postoperative following a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigation (CBI). Which of the following findings indicate a potential complication that requires immediate notification to the registered nurse? (Select all that apply)

  1. A sudden transition of irrigation drainage from light pink to bright red with large, thick clots.Cevap
  2. A resting heart rate of 118 beats/min118\text{ beats/min} and a blood pressure of 88/54 mm Hg88/54\text{ mm Hg}.Cevap
  3. Client report of severe, continuous lower abdominal cramping that is unrelieved by the prescribed antispasmodic medication.Cevap
  4. D
    The continuous bladder irrigation drainage bag contains 1,500 mL1,500\text{ mL} of light pink fluid.
  5. E
    The client's most recent laboratory results show a hemoglobin level of 14.2 g/dL14.2\text{ g/dL} (142 g/L142\text{ g/L}).
  6. F
    The client reports a constant, uncomfortable urge to urinate.

Cevap

The findings requiring immediate notification are the bright red drainage with large clots, the vital signs indicating shock (heart rate 118, BP 88/54), and the severe unrelieved abdominal cramping.
The correct findings represent three major life-threatening complications of a transurethral resection of the prostate (TURP): active arterial hemorrhage (indicated by bright red drainage with thick clots), systemic hypovolemic shock (indicated by tachycardia and hypotension), and severe catheter obstruction or bladder rupture (indicated by severe, unrelieved cramping). These findings require immediate escalation to the registered nurse to prevent permanent injury or death.

Adım Adım Çözüm

1
Analyze the client's surgical procedure (TURP with CBI) to identify high-risk postoperative complications.
The primary risks include hemorrhage, catheter obstruction by clots, and fluid volume imbalances.
Understanding the specific risks of the procedure provides the framework for evaluating clinical data.
2
Evaluate each clinical finding to determine if it represents an expected postoperative outcome or a critical deviation.
Light pink drainage, normal hemoglobin, and the urge to void are expected. Bright red blood, hypotension with tachycardia, and unrelieved severe pain are abnormal.
The practical nurse must differentiate between normal physiological responses to the catheter and life-threatening emergencies.
3
Select the findings that pose an immediate risk to the client's airway, breathing, circulation, or organ integrity.
The correct selections relate directly to hemorrhage/shock (circulation) and severe obstruction.
Findings that threaten ABCs require immediate escalation to the registered nurse for rapid medical intervention.

Anahtar Kavram

Postoperative TURP complications and continuous bladder irrigation management.
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Konular

Reduction of Risk Potential

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