HESI Case Study - Benign Prostatic Hyperplasia (2023)

While the client is awaiting transport to the operating room, which nursing staff member should be assigned to his care?

A PN who has worked on the unit for 3 years. A PN, with direct RN oversight, has experience in the care of clients on this unit. They have the ability to continue to monitor this unstable client until they are taken to the operating room. The PN should frequently update the RN and/or RN charge nurse of any new developments.

What focused assessment data could indicate the onset of a thrombotic complication?

Chest pain and dyspnea. Common manifestations of pulmonary embolism are chest pain and dyspnea.

What actions should the nurse take? (Select all that apply.)

Increase the flow rate of the CBI. The flow rate of the CBI should be increased, to decrease the risk for blood clot obstruction to the catheter. Notify the HCP of the findings. Bright red bleeding with increased viscosity is an indication of arterial bleeding. The HCP should be notified immediately to determine the course of action necessary. In addition, the flow rate of the CBI should be increased or manual irrigation performed to decrease the risk for blood clot obstruction of the catheter. Perform manual irrigation. Manual irrigation can be performed to help prevent blood clot obstruction and to resolve obstruction to the catheter.

The nurse instructs the UAP to place the emergency cart bedside. What is the next action the nurse should implement?

Notify the laboratory of the transfusion reaction. The next step in managing the transfusion reaction is to notify the lab so they can begin the transfusion reaction workup.

The nurse initiates a focused physical examination to further investigate the client's symptoms. Which assessment finding would indicate that the client is experiencing urinary retention related to BPH? (Select all that apply.)

Observance of bladder distention. Bladder distention is an assessment finding in urinary retention Bladder is above the symphysis pubis when gently palpated. A distended bladder will be palpable as an ovid (oval) shape above the symphysis pubis. Observance of dribbling after voiding. This is a symptom of urinary retention.

Which nursing intervention best promotes effective communication regarding follow up care?

Provide the client with written information explaining the need for yearly rectal exams and PSA screenings. Since the prostate gland is only partially removed during TURP, annual rectal exams and PSA screenings for prostate cancer should still be performed.

Which nursing intervention best promotes effective communication while teaching the client about contracting pelvic floor muscles?

Squeeze as if stopping the flow of urine. This best describes how to contract the pelvic floor muscles. After holding the contraction for 5 seconds, the client should relax for 5-10 seconds, and repeat 15-20 times TID. These exercises are also called Kegel exercises.

What action should the nurse take?

Stop the CBI, and irrigate the catheter. The catheter is most likely obstructed by blood clots and should be manually irrigated with 50 ml of sterile, 0.9% sodium chloride. The nurse should first check to make sure there are no kinks in the drainage tubing or other obvious signs of catheter obstruction!

What action is most important for the nurse to take regarding the partner's minimal eye contact?

Tell the partner you noticed they appeared to look away when you were speaking. Avoiding eye contact or engaging in minimal eye contact should be addressed. This would be a common response when someone is uncomfortable and not handling a stressfull or unknown situation.

What information should be included when teaching the client about terazosin?

This medication can cause dizziness so it should be taken at night. Terazosin is an alpha-adrenergic blocking agent and is likely to cause orthostatic hypotension and dizziness, especially when the client first starts the medication. It is recommended to take the medication at night.

The HCP prescribes an infusion of aminocaproic acid. The prescription is for a loading dose of aminocaproic acid IV 5 grams to be infused in 250 mL of 5% dextrose over 1 hour. The tubing drop factor is 15 gtt/mL. How many gtts/minute would the nurse set for the IV rate?

63

The nurse is monitoring the client and preparing client for surgery. Which task is within the scope of practice for the PN to complete?

Prepare a client with renal failure for a scheduled dialysis treatment. This client is stable, and this task does not require the expertise of the RN.

Which action should the nurse implement first?

Assess the client for additional symptoms. The client is exhibiting signs of a possible transfusion reaction. The nurse should immediately assess the client for additional symptoms, such as the presence of fever or chills, and then obtain vital signs

Which focused assessment finding warrants intervention by the nurse?

Confused to surroundings. Confusion is an acute symptom of cerebral hypoxia and require immediate intervention.

What action should the nurse take?

Document that the CBI is infusing correctly. Normal drainage is reddish pink, clearing to light pink within 24 hours postoperatively. The drainage should be clear yellow by the 4th postoperative day. 0.9% sodium chloride is the desired solution for irrigation because it is isotonic. Hypotonic or hypertonic solutions may result in fluid shifts.

Which information is most important for the nurse to include when explaining the need for these tests? (Select all that apply.)

Emphasize to the client that prostate enlargement may result in renal damage which these tests will evaluate. Prostate enlargement may result in kidney damage, which can cause a change in urine production. Inform the client that repeat testing is necessary as an enlarged prostate gland blocks urine flow and causes kidney damage. As the flow of urine is blocked by the enlarged prostate gland, gradual dilation of the ureters (hydroureter) and kidneys (hydronephrosis) can occur, resulting in increased creatinine and BUN levels. Advise the client that it is protocol for the healthcare provider (HCP) to conduct then recheck tests to compare previous results. It is important to monitor progression and degree of kidney damage.

Which intervention should the nurse implement to address the client's concern?

Explain that PSA levels can be elevated with gland enlargement, as well as cancer, so more tests are needed. Elevated PSA levels are associated with prostate cancer. However, slight elevations may also occur in BPH. PSA levels may also be elevated as the result of infection, or if the prostate gland is manipulated during a digital rectal exam.

Which of the client's serum laboratory values requires immediate intervention by the nurse?

Hematocrit 28 % (0.28) Normal hematocrit is 37 - 46 % (0.37 - 0.46). A low hematocrit would be expected in hypovolemic shock secondary to hemorrhage and requires immediate intervention.

The client tells the nurse that he has cut back on drinking fluids to reduce symptoms. Which instruction is most important for the nurse to provide to the client?

Increase fluid intake to decrease the risk of developing a urinary tract infection. Clients with BPH often restrict fluid intake to reduce symptoms, but this should be discouraged because it increases the risk for urinary tract infection.

What action should the nurse take next after stopping the transfusion?

Infuse 0.9% sodium chloride solution through separate IV tubing. After stopping the blood transfusion, the nurse should next infuse 0.9% sodium through a separate IV tubing to maintain IV patency. The client may experience shock and may need additional fluids and medications.

What action by the nurse would indicate a breech of duty.

Initial blood transfusion rate 10 mL/min for the first 15 minutes. Breach of duty is the failure to perform according to established standards, such as those define in the Infusion Nursing Society.

Which nursing intervention best promotes effective communication?

Instruct the client to try not to bear down around the catheter. The client could damage the urinary sphincter if he tries to void around the catheter. Bearing down to try to urinate will create more pressure on the sphincter.

Aware of the client's partner's body language, what action should the nurse implement?

Let the client's partner know that you will be glad to answer any questions they may have. This response gives the partner the opportunity to choose any further interaction, which include avoidance of physical touch between persons who are not close.

Which nursing interventions promotes effective communication when teaching the client about finasteride? (Select all that apply.)

Liver function studies (LFTs) need to be monitored frequently. Finasteride can cause hepatic dysfunction, so liver function tests results should be reviewed periodically. Most clients see significant change in BPH symptoms in 4 months. It may take 12 weeks to 6 months to achieve the desired response. Protect the medication from light. Finasteride should be protected from the light. Clients can experience breast enlargement. One of the adverse effects of finasteride is breast enlargement and tenderness.

Which postoperative intervention should the nurse perform first?

Observe the urinary drainage. A common postoperative complication that can be potentially life-threatening is bleeding, which will be seen in the urinary drainage

Which nursing intervention best promotes effective communication by the charge nurse?

Review blood transfusion interventions with the nurse. This is an assertive response by the charge nurse and offers both nurses an opportunity to review the situation to determine variations from policy and any evidence of negligence.

Which assessment findings warrants immediate intervention by the nurse? (Select all that apply.)

Sudden painful inability to urinate. This is a sign of acute obstruction and requires an indwelling urinary catheter to allow urine to drain Painful, frequent urination. This is a sign of urinary tract infection that requires antibiotic therapy as soon as possible

The client arrives at the clinic early for the uroflowmetry test and is asking the nurse to explain the procedure. Which nursing intervention best promotes effective communication?

Uroflowmetry is a non-invasive exam to measure the volume and flow of urine. Uroflowmetry is a simple non-invasive procedure that measures the flow of urine which can indicate the extent of blockage the prostate is creating.

Which action should the nurse ensure is implemented to reduce the risk for a hemolytic transfusion reaction?

Verify the blood type and Rh factor with the RN who will start, and monitor, the infusion for the first 15-30 minutes. Acute hemolytic reactions are the result of the infusion of incompatible blood products. This risk is reduced if two nurses verify and compare the label on the blood with the client's identification band and the blood bank form. In addition, the transfusion should be started slowly, and the client should be observed carefully during the first 15 to 30 minutes of the transfusion

Which instruction should the nurse provide to the client before starting the procedure?

While voiding into a special toilet, urine flow pressure will be monitored. The pressure of the urine flow is measured to determine the degree of obstruction.