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    Nclex-Pn Readiness Test 6Question 103
    103 / 150
    Adult Health

    The client arrived at the medical-surgical unit six hours post-operative from a TURP. The client was alert, oriented to person, place, time, and situation. The client has a three-way indwelling urinary catheter and is continuously irrigated with isotonic saline. Urine output is ketchup-like with medium to large clots. The client reports the need to urinate and reported pressure in the pelvic region described as spasms.

    Intake – Continuous bladder irrigation: 550 mL

    Output – Indwelling catheter: 975 mL

    Blood Pressure 100/60 mm Hg

    Temperature 98° F (36.7° C)

    Heart rate 106/min

    Respiratory rate 19 breaths per minute

    Oxygen saturation 95% on room air

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