Question: After a transurethral prostatectomy, a client returns to the postanesthesia care unit with a three-way indwelling catheter with continuous bladder irrigation. What nursing action is the priority?
1. Monitoring for signs of confusion
2. Observing the suprapubic dressing for drainage
3. Maintaining the client in the semi-Fowler position
4. Encouraging fluids by mouth as soon as the gag reflex returns
Rationale: Confusion is a response to cerebral edema. Cerebral edema is a complication of continuous bladder irrigation because of an excessive absorption of irrigating solution by the venous sinusoids during surgery. The surgery is performed through the urinary meatus and urethra; there is no suprapubic incision. It is unnecessary to keep the client in the semi-Fowler’s position. The client is initially NPO and then advanced to a regular diet as tolerated. Continuous irrigation supplies enough fluid to flush the bladder.
Clinical Area: Medical-Surgical Nursing
Client Needs: Reduction of Risk Potential
Cognitive Level: Application
Nursing Process: Planning
This week’s NCLEX exam practice question came from:
Nugent: Mosby's Review Questions for the NCLEX-RN Examination, 7th Edition, Chapter 6, Page 501, Question 21
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