Benign Prostatic Hyperplasia HESI Bob Hamilton
Which instruction should the nurse provide to Mr. Hamilton before starting the procedure?
"Empty your bladder completely."
What is the best response by the nurse?
"I will be glad to answer any questions you may have."
How should the nurse respond?
"You will still need yearly rectal exams and PSA screenings."
What is the best initial response by the charge nurse?
"Describe everything you did that is related to the transfusion."
What instructions should the nurse relate to Mr. Hamilton?
"Do not try to void around the catheter."
What action should the nurse take?
Document that the CBI is infusing correctly.
What actions should the nurse take?
Increase the flow rate of the CBI. Notify the HCP of the findings. Perform manual irrigation.
How can the nurse best interpret Mrs. Hamilton's minimal eye contact, in light of Mrs. Hamilton's cultural background?
A cultural practice based on recognition of someone's social status.
What statement best describes this term?
A nurse's actions do not meet established standards.
While the nurse is monitoring Mr. Hamilton closely, which additional responsibility is best to assign to the LPN?
Prepare a client with renal failure for a scheduled dialysis treatment.
Which catheter should the nurse select to perform the procedure?
12 French straight catheter.
to be infused in 250 mL of D5W over 1 hour. The tubing drop factor is 15 drops/mL. How many drops per minute would the nurse set for the IV rate?
63 Amount X Drop Factor \ Time to Infuse 250 X 15\60 minutes = 62.5= 63 drops/minute
What analogy can the nurse use to describe how to contract the pelvic floor muscles?
Squeeze as if stopping the flow of urine.
What action should the nurse take?
Stop the CBI, and irrigate the catheter.
Which nursing diagnosis has the highest priority when implementing care?
Altered cardiac output.
While Mr. Hamilton is awaiting transport to the Operating Room (OR), which nursing staff member should be assigned to his care?
An RN who has worked on the unit for 3 years.
Which action should the nurse implement first?
Assess Mr. Hamilton for additional symptoms.
What assessment data would indicate the onset of a thrombotic complication?
Chest pain and dyspnea.
Mr. Hamilton tells the nurse that he has cut back on drinking fluids to reduce his symptoms. Which instruction is most important for the nurse to provide to Mr. Hamilton?
Decrease fluid intake to increase the risk of developing a urinary tract infection.
Which action by the nurse is most helpful?
Explain that PSA levels can be elevated with gland enlargement, as well as cancer, so more tests are needed.
Which information should be included in the nurse's explanation?
Prostate enlargement may result in renal damage, causing a decreased of urine production in the kidneys, which these tests will evaluate. When the prostate gland is blocking the flow of urine, some degree of kidney damage that can be detected with these tests.
Which lab value would the nurse question?
Hemoglobin 15.0 g/dL.
Which additional manifestations would the nurse expect in clients with BPH?
Hesitancy when starting the urine stream. Decrease in the size and force of urine stream. Frequent urination, including nocturia.
What action should the nurse take next after stopping the transfusion?
Infuse normal saline solution through separate IV tubing.
What does Mr. Hamilton need to know about taking finasteride (Proscar)?
Liver function studies (LFTs) need to be monitored frequently. Most clients see significant change in BPH symptoms in 4 months. Protect the medication from light. Clients can experience breast enlargement.
The nurse initiates a physical examination to further investigate Mr. PerryHamilton's symptoms. Which assessment finding would indicate that Mr. Hamilton is experiencing urinary retention?
Observance of bladder distention. Dullness heard on percussion below the umbilicus. Observance of dribbling after voiding.
Which postoperative intervention should the nurse perform first?
Observe the urinary drainage.
In what position should the nurse place Mr. Hamilton?
Supine with feet elevated at a 45 degree angle.
What information should be included when teaching Mr. Hamilton about terazosin (Hytrin)?
This medication can cause dizziness so it should be taken at night.
Which action should the nurse implement to reduce the risk for a hemolytic transfusion reaction?
Verify the blood type and Rh factor with another nurse.