Author Question: The nurse is caring for a patient who had prostate surgery the previous day. The patient has had ... (Read 26 times)

ahriuashd · **on:** Jul 23, 2018

The nurse is caring for a patient who had prostate surgery the previous day. The patient has had significantly decreased urine output over the last shift despite ample oral and IV fluid intake.

The patient's urine from the indwelling catheter is cherry red with occasional small clots. What is the appropriate action of the nurse?
a.
Remove the urinary catheter and replace it with a new one
b.
Gently irrigate the catheter using warmed sterile normal saline
c.
Send a sample of the patient's urine to the laboratory for analysis
d.
Call the physician and obtain an order for kidney and bladder ultrasound

Question 2

The nurse is caring for a patient with benign prostatic hypertrophy who states that he feels a constant urge to urinate but cannot pass more than 30 to 60 mL of urine into the toilet at a time.

The nurse performs a bladder scan and finds that there are 1100 mL of urine in the patient's bladder. What is the priority nursing diagnosis for this patient?
a.
Alteration in comfort r/t continual urge to urinate
b.
Overflow urinary incontinence r/t over-distention of the bladder
c.
Urinary retention r/t obstruction of urinary bladder outlet
d.
Toileting self-care deficit r/t inability to pass urine into the toilet

jlaineee · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: B
The patient most likely has decreased urine output caused by clot formation that is blocking urine from draining through the catheter. The catheter should be gently irrigated using sterile technique and warmed sterile saline to loosen clots and facilitate urinary drainage. The catheter should not be removed. Ultrasound and urinalysis are not necessary.

Answer to Question 2

ANS: C
The patient has acute urinary retention with overflow as evidenced by 1100 mL of urine in the bladder and frequent passage of small amounts of urine. The priority nursing diagnosis is thus urinary retention r/t obstruction of urinary bladder outlet. Urinary retention is the cause of the patient's discomfort and drainage of the bladder will result in relief of the patient's symptoms. The patient is able to get himself on and off the toilet so toileting self-care deficit is not a problem. Overflow urinary incontinence is not applicable because the patient is passing the urine into the toilet.