Chapter 54: Male Reproductive and Genital Problems Lewis: Medical-Surgical Nursing, 10th Edition

When performing discharge teaching for a patient after a vasectomy, the nurse instructs the patient that he a. should continue to use other methods of birth control for 6 weeks. b. should not have sexual intercourse until his 6-week follow-up visit. c. may have temporary erectile dysfunction (ED) because of swelling. d. will notice a decrease in the appearance and volume of his ejaculate.

ANS: A Because it takes about 6 weeks to evacuate sperm that are distal to the vasectomy site, the patient should use contraception for 6 weeks. ED that occurs after vasectomy is psychologic in origin and not related to postoperative swelling. The patient does not need to abstain from intercourse. The appearance and volume of the ejaculate are not changed because sperm are a minor component of the ejaculate. DIF: Cognitive Level: Understand (comprehension) REF: 1286 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

To determine the severity of the symptoms for a patient with benign prostatic hyperplasia (BPH), the nurse will ask the patient about a. blood in the urine. . b. lower back or hip pain. c. force of urinary stream d. erectile dysfunction (ED).

ANS: C The American Urological Association Symptom Index for a patient with BPH asks questions about the force and frequency of urination, nocturia, and so on. Blood in the urine, ED, and back or hip pain are not typical symptoms of BPH. DIF: Cognitive Level: Apply (application) REF: 1268 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A 22-yr-old patient tells the nurse at the health clinic that he has recently had some problems with erectile dysfunction. Which question should the nurse ask to assess for possible etiologic factors in this age group? a. "Do you use recreational drugs or drink alcohol?" b. "Do you experience an unusual amount of stress?" c. "Do you have cardiovascular or peripheral vascular disease?" d. "Do you have a history of an erection that lasted for 6 hours or more?"

ANS: A A common etiologic factor for erectile dysfunction (ED) in younger men is use of recreational drugs or alcohol. Stress, priapism, and cardiovascular illness also contribute to ED, but they are not common etiologic factors in younger men. DIF: Cognitive Level: Apply (application) REF: 1287 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A 70-yr-old patient who has had a transurethral resection of the prostate (TURP) for benign prostatic hyperplasia (BPH) is being discharged from the hospital today. Which patient statement indicates a need for the nurse to provide additional instruction? a. "I should call the doctor if I have incontinence at home." b. "I will avoid driving until I get approval from my doctor." c. "I should schedule yearly appointments for prostate examinations." d. "I will increase fiber and fluids in my diet to prevent constipation."

ANS: A Because incontinence is common for several weeks after a TURP, the patient does not need to call the health care provider if this occurs. The other patient statements indicate that the patient has a good understanding of post-TURP instructions. DIF: Cognitive Level: Apply (application) REF: 1274 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

A patient with urinary obstruction from benign prostatic hyperplasia (BPH) tells the nurse, "My symptoms are much worse this week." Which response by the nurse is appropriate? a. "Have you taken any over-the-counter (OTC) medications recently?" b. "I will talk to the doctor about a prostate specific antigen (PSA) test." c. "Have you talked to the doctor about surgery such as transurethral resection of the prostate (TURP)?" d. "The prostate gland changes in size from day to day, and this may be making your symptoms worse."

ANS: A Because the patient's increase in symptoms has occurred abruptly, the nurse should ask about OTC medications that might cause contraction of the smooth muscle in the prostate and worsen obstruction. The prostate gland does not vary in size from day to day. A TURP may be needed, but more assessment about possible reasons for the sudden symptom change is a more appropriate first response by the nurse. PSA testing is done to differentiate BPH from prostatic cancer. DIF: Cognitive Level: Apply (application) REF: 1273 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse will inform a patient with cancer of the prostate that side effects of leuprolide (Lupron) may include a. flushing. c. infection. b. dizziness. d. incontinence.

ANS: A Hot flashes may occur with decreased testosterone production. Dizziness may occur with the a-blockers used for benign prostatic hyperplasia. Urinary incontinence may occur after prostate surgery, but it is not an expected side effect of medication. Risk for infection is increased in patients receiving chemotherapy. DIF: Cognitive Level: Understand (comprehension) REF: 1280 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse will plan to teach a 67-yr-old patient who has been diagnosed with orchitis about a. pain management. b. emergency surgery. c. application of heat to the scrotum. d. aspiration of fluid from the scrotal sac.

ANS: A Orchitis is very painful, and effective pain management will be needed. Heat, aspiration, and surgery are not used to treat orchitis. DIF: Cognitive Level: Apply (application) REF: 1284 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

Several patients call the urology clinic requesting appointments with the health care provider as soon as possible. Which patient will the nurse schedule to be seen first? a. A 22-yr-old patient who has noticed a firm, nontender lump on his scrotum b. A 35-yr-old patient who is concerned that his scrotum "feels like a bag of worms" c. A 40-yr-old patient who has pelvic pain while being treated for chronic prostatitis d. A 70-yr-old patient who is reporting frequent urinary dribbling after a prostatectomy

ANS: A The patient's age and symptoms suggest possible testicular cancer. Some forms of testicular cancer can be very aggressive, so the patient should be evaluated by the health care provider as soon as possible. Varicoceles do require treatment but not emergently. Ongoing pelvic pain is common with chronic prostatitis. Urinary dribbling is a common problem after prostatectomy. DIF: Cognitive Level: Analyze (analysis) REF: 1285 OBJ: Special Questions: Multiple Patients | Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

The following male patients recently arrived in the emergency department. Which one should the nurse assess first? a. A 19-yr-old patient who is complaining of severe scrotal pain b. A 60-yr-old patient with a nontender ulceration of the glans penis c. A 64-yr-old patient who has dysuria after brachytherapy for prostate cancer d. A 22-yr-old patient who has purulent urethral drainage and severe back pain

ANS: A The patient's age and symptoms suggest possible testicular torsion, which will require rapid treatment to prevent testicular necrosis. The other patients also require assessment by the nurse, but their history and symptoms indicate nonemergent problems (acute prostatitis, cancer of the penis, and radiation-associated urinary tract irritation). DIF: Cognitive Level: Analyze (analysis) REF: 1285 OBJ: Special Questions: Prioritization | Special Questions: Multiple Patients TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

The health care provider prescribes finasteride (Proscar) for a patient who has benign prostatic hyperplasia (BPH). When teaching the patient about the drug, the nurse informs him that a. he should change position from lying to standing slowly to avoid dizziness. b. his interest in sexual activity may decrease while he is taking the medication. c. improvement in the obstructive symptoms should occur within about 2 weeks. d. he will need to monitor his blood pressure frequently to assess for hypertension.

ANS: B A decrease in libido is a side effect of finasteride because of the androgen suppression that occurs with the drug. Although orthostatic hypotension may occur if the patient is also taking a medication for erectile dysfunction, it should not occur with finasteride alone. Improvement in symptoms of obstruction takes about 6 months. The medication does not cause hypertension. DIF: Cognitive Level: Apply (application) REF: 1271 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A 58-yr-old patient with erectile dysfunction (ED) tells the nurse he is interested in using sildenafil (Viagra). Which action should the nurse take first? a. Assure the patient that ED is common with aging. b. Ask the patient about any prescription drugs he is taking. c. Tell the patient that Viagra does not always work for ED. d. Discuss the common adverse effects of erectogenic drugs.

ANS: B Because some medications can cause ED and patients using nitrates should not take sildenafil, the nurse should first assess for prescription drug use. The nurse may want to teach the patient about realistic expectations and adverse effects of sildenafil therapy, but this should not be the first action. Although ED does increase with aging, it may be secondary to medication use or cardiovascular disease. DIF: Cognitive Level: Analysis (analyze) REF: 1288 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse will plan to teach the patient who is incontinent of urine following a radical retropubic prostatectomy to a. restrict oral fluid intake. b. do pelvic muscle exercises. c. perform intermittent self-catheterization. d. use belladonna and opium suppositories.

ANS: B Pelvic floor muscle training (Kegel) exercises are recommended to strengthen the pelvic floor muscles and improve urinary control. Belladonna and opium suppositories are used to reduce bladder spasms after surgery. Intermittent self-catheterization may be taught before surgery if the patient has urinary retention, but it will not be useful in reducing incontinence after surgery. The patient should have a daily oral intake of 2 to 3 L. DIF: Cognitive Level: Apply (application) REF: 1278 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

The nurse performing a focused examination to determine possible causes of infertility will assess for a. hydrocele. c. epididymitis. b. varicocele. d. paraphimosis.

ANS: B Persistent varicoceles are commonly associated with infertility. Hydrocele, epididymitis, and paraphimosis are not risk factors for infertility. DIF: Cognitive Level: Understand (comprehension) REF: 1285 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse in a health clinic receives requests for appointments from several patients. Which patient should be seen by the health care provider first? a. A 48-yr-old patient who has perineal pain and a temperature of 100.4° F b. A 58-yr-old patient who has a painful erection that has lasted more than 6 hours c. A 38-yr-old patient who reports that he had difficulty maintaining an erection twice last week d. A 68-yr-old patient who has pink urine after a transurethral resection of the prostate (TURP) 3 days ago

ANS: B Priapism can cause complications such as necrosis or hydronephrosis, and this patient should be treated immediately. The other patients do not require immediate action to prevent serious complications. DIF: Cognitive Level: Analyze (analysis) REF: 1283 OBJ: Special Questions: Multiple Patients | Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

The nurse in the clinic notes elevated prostate specific antigen (PSA) levels in the laboratory results of these patients. Which patient's PSA result is not expected to be elevated? a. A 38-yr-old patient who is being treated for acute prostatitis b. A 48-yr-old patient whose father died of metastatic prostate cancer c. A 52-yr-old patient who goes on long bicycle rides every weekend d. A 75-yr-old patient who uses saw palmetto to treat benign prostatic hyperplasia (BPH)

ANS: B The family history of prostate cancer and elevation of PSA indicate that further evaluation of the patient for prostate cancer is needed. Elevations in PSA for the other patients are not unusual. DIF: Cognitive Level: Apply (application) REF: 1281 OBJ: Special Questions: Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

A 27-yr-old patient who has testicular cancer is being admitted for a unilateral orchiectomy. The patient does not talk to his wife and speaks to the nurse only to answer the admission questions. Which action is appropriate for the nurse to take? a. Teach the patient and the wife that impotence is unlikely after unilateral orchiectomy. b. Ask the patient if he has any questions or concerns about the diagnosis and treatment. c. Inform the patient's wife that concerns about sexual function are common with this diagnosis. d. Document the patient's lack of communication on the health record and continue preoperative care.

ANS: B The initial action by the nurse should be assessment for any anxiety or questions about the surgery or postoperative care. The nurse should address the patient, not the spouse, when discussing the diagnosis and any possible concerns. Without further assessment of patient concerns, the nurse should not offer teaching about complications after orchiectomy. Documentation of the patient's lack of interaction is not an adequate nursing action in this situation. DIF: Cognitive Level: Apply (application) REF: 1280 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

A patient who has benign prostatic hyperplasia (BPH) with urinary retention is admitted to the hospital with elevated blood urea nitrogen (BUN) and creatinine. Which prescribed therapy should the nurse implement first? a. Infuse normal saline at 50 mL/hr. b. Insert a urinary retention catheter. c. Draw blood for a complete blood count. d. Schedule pelvic magnetic resonance imaging

ANS: B The patient data indicate that the patient may have acute kidney injury caused by the BPH. The initial therapy will be to insert a catheter. The other actions are also appropriate, but they can be implemented after the acute urinary retention is resolved. DIF: Cognitive Level: Analyze (analysis) REF: 1269 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse will plan to teach the patient scheduled for photovaporization of the prostate (PVP) a. that urine will appear bloody for several days. b. how to care for an indwelling urinary catheter. c. that symptom improvement takes 2 to 3 weeks. d. about complications associated with urethral stenting.

ANS: B The patient will have an indwelling catheter for 24 to 48 hours and will need teaching about catheter care. There is minimal bleeding with this procedure. Symptom improvement is almost immediate after PVP. Stent placement is not included in the procedure. DIF: Cognitive Level: Apply (application) REF: 1272 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient tells the nurse that he decided to seek treatment for erectile dysfunction (ED) because his wife "is losing patience with the situation." The nurse's follow-up questions should focus on the man's identified concern with a. low self-esteem. c. increased anxiety. b. role performance. d. infrequent intercourse.

ANS: B The patient's statement indicates that the relationship with his wife is his primary concern. Although anxiety, low self-esteem, and ineffective sexuality patterns may also be concerns, the patient information suggests that addressing the role performance problem will lead to the best outcome for this patient. DIF: Cognitive Level: Apply (application) REF: 1288 TOP: Nursing Process: Intervention MSC: NCLEX: Psychosocial Integrity

Which information will the nurse plan to include when teaching a young adult who has a family history of testicular cancer about testicular self-examination? a. Testicular self-examination should be done at least weekly. b. Testicular self-examination should be done in a warm room. c. The only structure normally felt in the scrotal sac is the testis. d. Call the health care provider if one testis is larger than the other.

ANS: B The testes will hang lower in the scrotum when the temperature is warm (e.g., during a shower), and it will be easier to palpate. The epididymis is also normally palpable in the scrotum. One testis is normally larger. Men at high risk should perform testicular self-examination monthly. DIF: Cognitive Level: Understand (comprehension) REF: 1286 TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance

When caring for a patient with continuous bladder irrigation after having transurethral resection of the prostate, which action could the nurse delegate to unlicensed assistive personnel (UAP)? a. Teach the patient how to perform Kegel exercises. b. Report any complaints of pain or spasms to the nurse. c. Monitor for increases in bleeding or presence of clots. d. Increase the flow rate of the irrigation if clots are noted.

ANS: B UAP education and role includes reporting patient concerns to supervising nurses. Patient teaching, assessments for complications, and actions such as bladder irrigation require more education and should be done by licensed nursing staff. DIF: Cognitive Level: Apply (application) REF: 1274 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

The nurse taking a focused health history for a patient with possible testicular cancer will ask the patient about a history of a. testicular torsion. b. testicular trauma. c. undescended testicles. d. sexually transmitted infection (STI).

ANS: C Cryptorchidism is a risk factor for testicular cancer if it is not corrected before puberty. STI, testicular torsion, and testicular trauma are risk factors for other testicular conditions but not for testicular cancer. DIF: Cognitive Level: Understand (comprehension) REF: 1284 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

A 53-yr-old patient is scheduled for an annual physical examination. The nurse will plan to teach the patient about the purpose of a. urinalysis collection. b. uroflowmetry studies. c. prostate specific antigen (PSA) testing. d. transrectal ultrasound scanning (TRUS).

ANS: C An annual digital rectal exam (DRE) and PSA are usually recommended starting at age 50 years for men who have an average risk for prostate cancer. Urinalysis and uroflowmetry studies are done if patients have symptoms of urinary tract infection or changes in the urinary stream. TRUS may be ordered if the DRE or PSA results are abnormal. DIF: Cognitive Level: Apply (application) REF: 1273 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient who has been recently diagnosed with benign prostatic hyperplasia (BPH) tells the nurse that he does not want to have a transurethral resection of the prostate (TURP) because it might affect his ability to have sexual intercourse. Which action should the nurse take? a. Discuss alternative methods of sexual expression. b. Teach about medication for erectile dysfunction (ED). c. Clarify that TURP does not commonly affect erection. d. Offer reassurance that fertility is not affected by TURP.

ANS: C ED is not a concern with TURP, although retrograde ejaculation is likely, and the nurse should discuss this with the patient. Erectile function is not usually affected by a TURP, so the patient will not need information about penile implants or reassurance that other forms of sexual expression may be used. Because the patient has not asked about fertility, reassurance about sperm production does not address his concerns. DIF: Cognitive Level: Apply (application) REF: 1272 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which information will the nurse teach a patient who has chronic prostatitis? a. Ibuprofen (Motrin) should provide good pain control. b. Prescribed antibiotics should be taken for 7 to 10 days. c. Intercourse or masturbation will help relieve symptoms. d. Cold packs used every 4 hours will decrease inflammation.

ANS: C Ejaculation helps drain the prostate and relieve pain. Warm baths are recommended to reduce pain. Nonsteroidal antiinflammatory drugs (NSAIDs) are frequently prescribed but usually do not offer adequate pain relief. Antibiotics for chronic prostatitis are taken for 4 to 12 weeks. DIF: Cognitive Level: Apply (application) REF: 1283 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which action by the unlicensed assistive personnel (UAP) who are assisting with the care of male patients with reproductive problems indicates that the nurse should provide more teaching? a. The UAP apply a cold pack to the scrotum for a patient with mumps orchitis. b. The UAP help a patient who has had a prostatectomy to put on antiembolism hose. c. The UAP leave the foreskin pulled back after cleaning the glans of a patient who has a retention catheter. d. The UAP encourage a high oral fluid intake for patient who had transurethral resection of the prostate yesterday.

ANS: C Paraphimosis can be caused by failing to replace the foreskin back over the glans after cleaning. The other actions by UAP are appropriate. DIF: Cognitive Level: Apply (application) REF: 1274 OBJ: Special Questions: Delegation TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

The nurse is obtaining the pertinent health history for a man who is being evaluated for infertility. Which question focuses on a possible cause of infertility? a. "Are you circumcised?" b. "Have you had surgery for phimosis?" c. "Do you use medications to improve muscle mass?" d. "Is there a history of prostate cancer in your family?"

ANS: C Testosterone or testosterone-like medications may adversely affect sperm count. The other information will be obtained in the health history but does not affect the patient's fertility. DIF: Cognitive Level: Apply (application) REF: 1289 TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance

The plan of care for a patient immediately after a perineal radical prostatectomy will include decreasing the risk for infection related to a. urinary incontinence. c. fecal wound contamination. b. prolonged urinary stasis. d. suprapubic catheter placement.

ANS: C The perineal approach increases the risk for infection because the incision is located close to the anus, and contamination with feces is possible. Urinary stasis and incontinence do not occur because the patient has a retention catheter in place for 1 to 2 weeks. A urethral catheter is used after the surgery. DIF: Cognitive Level: Apply (application) REF: 1278 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

The health care provider prescribes the following interventions for a patient with acute prostatitis caused by Escherichia coli. Which intervention should the nurse question? a. Give trimethoprim/sulfamethoxazole 1 tablet daily for 28 days. b. Administer ibuprofen 400 mg every 8 hours as needed for pain. c. Instruct patient to avoid sexual intercourse until treatment is complete. d. Catheterize the patient as needed if symptoms of urinary retention develop.

ANS: D Although acute urinary retention may occur, insertion of a catheter through an inflamed urethra is contraindicated, and the nurse will anticipate that the health care provider will need to insert a suprapubic catheter. The other actions are appropriate. DIF: Cognitive Level: Apply (application) REF: 1282 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

The nurse will anticipate that a 61-yr-old patient who has an enlarged prostate detected by digital rectal examination (DRE) and an elevated prostate specific antigen (PSA) level will need teaching about a. cystourethroscopy. b. uroflowmetry studies. c. magnetic resonance imaging (MRI). d. transrectal ultrasonography (TRUS).

ANS: D In a patient with an abnormal DRE and elevated PSA, transrectal ultrasound is used to visualize the prostate for biopsy. Uroflowmetry studies help determine the extent of urine blockage and treatment, but there is no indication that this is a problem for this patient. Cystoscopy may be used before prostatectomy but will not be done until after the TRUS and biopsy. MRI is used to determine whether prostatic cancer has metastasized but would not be ordered at this stage of the diagnostic process. DIF: Cognitive Level: Apply (application) REF: 1270 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient who has been diagnosed with stage 2 prostate cancer chooses the option of active surveillance. The nurse will plan to a. vaccinate the patient with sipuleucel-T (Provenge). b. provide the patient with information about cryotherapy. c. teach the patient about placement of intraurethral stents. d. schedule the patient for annual prostate-specific antigen testing.

ANS: D Patients who opt for active surveillance need to have annual digital rectal examinations and prostate-specific antigen testing. Vaccination with sipuleucel-T, cryotherapy, and stent placement are options for patients who choose to have active treatment for prostate cancer. DIF: Cognitive Level: Understand (comprehension) REF: 1269 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

After a transurethral resection of the prostate (TURP), a 64-yr-old patient with continuous bladder irrigation complains of painful bladder spasms. The nurse observes clots in the urine. Which action should the nurse take first? a. Increase the flow rate of the bladder irrigation. b. Administer the prescribed IV morphine sulfate. c. Give the patient the prescribed belladonna and opium suppository. d. Manually instill and then withdraw 50 mL of saline into the catheter.

ANS: D The assessment suggests that obstruction by a clot is causing the bladder spasms, and the nurse's first action should be to irrigate the catheter manually and to try to remove the clots. IV morphine will not decrease the spasm, although pain may be reduced. Increasing the flow rate of the irrigation will further distend the bladder and may increase spasms. The belladonna and opium suppository will decrease bladder spasms but will not remove the obstructing blood clot. DIF: Cognitive Level: Analysis (analyze) REF: 1272 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

Which assessment information collected by the nurse may present a contraindication to a testosterone replacement therapy (TRT)? a. The patient has noticed a decrease in energy level for a few years. b. The patient's symptoms have increased steadily over the past few years. c. The patient has been using sildenafil (Viagra) several times every week. d. The patient has had a gradual decrease in the force of his urinary stream.

ANS: D The decrease in urinary stream may indicate benign prostatic hyperplasia (BPH) or prostate cancer, which are contraindications to the use of testosterone replacement therapy (TRT). The other patient data indicate that TRT may be a helpful therapy for the patient. DIF: Cognitive Level: Apply (application) REF: 1269 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

Which information about continuous bladder irrigation will the nurse teach to a patient who is being admitted for a transurethral resection of the prostate (TURP)? a. Bladder irrigation decreases the risk of postoperative bleeding. b. Hydration and urine output are maintained by bladder irrigation. c. Antibiotics are infused continuously through the bladder irrigation. d. Bladder irrigation prevents obstruction of the catheter after surgery.

ANS: D The purpose of bladder irrigation is to remove clots from the bladder and prevent obstruction of the catheter by clots. The irrigation does not decrease bleeding or improve hydration. Antibiotics are given by the IV route, not through the bladder irrigation. DIF: Cognitive Level: Understand (comprehension) REF: 1274 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

ANS: B Bladder spasms and lack of urine output indicate that the nurse needs to assess the continuous bladder irrigation for kinks and may need to manually irrigate the patient's catheter. The other information will also require actions, such as having the patient take deep breaths and cough and discussing the need for antihypertensive medication prescriptions with the health care provider, but the nurse's first action should be to address the problem with the urinary drainage system. DIF: Cognitive Level: Apply (application) REF: 1274 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

After reviewing the electronic medical record shown in the accompanying figure for a patient who had transurethral resection of the prostate the previous day, which information requires the most rapid action by the nurse? a. Elevated temperature and pulse b. Bladder spasms and urine output c. Respiratory rate and lung crackles d. No prescription for antihypertensive drugs