A client is receiving a postoperative continuous bladder irrigation via a three-way indwelling catheter for a transurethral resection of the prostate (TURP). Twelve hours after the surgery, the practical nurse (PN) is monitoring the urine in the catheter's bedside drainage unit and observes that the drainage is a thick red fluid with clots. What action should the PN implement?

Check for kinks in the drainage tubing.

Observe the drainage again in one hour.

Report the finding to the charge nurse.

Stop the irrigation solution immediately

Answer and Explanation

The Correct Answer is C

A.   Checking for kinks in the drainage tubing might be a part of troubleshooting, but the observed clots and thick red fluid require immediate attention, so informing the charge nurse is the priority.
B.   Delaying assessment for another hour could potentially exacerbate the issue if there's a problem with the irrigation or if the client's condition worsens.
C.   Reporting the finding to the charge nurse is crucial as it indicates potential complications such as bleeding or clot formation that need immediate intervention.
D.   Immediately stopping the irrigation solution without proper assessment and guidance could lead to complications and isn't the initial action warranted in this situation.

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Correct Answer is B

Explanation

A. Auscultating for bowel sounds might be important, but checking the NGT suction status is a priority when a client with an NGT reports nausea to ensure proper functioning and appropriate suction level.

B. Ensuring the NGT suction is working properly addresses the immediate concern of potential gastric accumulation contributing to nausea.
C. Administering an antiemetic might provide relief, but assessing the NGT function takes priority to address the cause.
D. Observing the color of gastric drainage is essential but comes after verifying the NGT suction functioning in the context of the reported nausea.

A. Missing pulse. B. Thready pulse volume. C. Light pressure applied to pulse. D. Pulse skips beats.

Correct Answer is B

Explanation

A. Missing pulse. - This term implies the complete absence of a pulse, which might not be the case here; the pulse is present but disappears with light pressure.
B. Thready pulse volume. - A thready pulse refers to a weak pulse that is easily obliterated with light pressure. This accurately describes the finding observed by the PN.
C. Light pressure applied to pulse. - This description simply explains the technique used to assess the pulse and does not adequately capture the quality of the pulse.
D. Pulse skips beats. - This term refers to an irregularity in the pulse rhythm, not to the disappearance with light pressure.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A postoperative client with a nasogastric tube (NGT) to low-intermittent suction reports the onset of nausea. Which action should the practical nurse take first

Correct Answer is B

Explanation

The practical nurse (PN) palpates a client's radial pulse and notes that the pulse disappears when light pressure is applied. How should the PN document this finding?

Correct Answer is B

Explanation

The practical nurse (PN) overhears a conversation between an unlicensed assistive personnel (UAP) and another staff member in the hospital cafeteria line concerning a client's reaction to being given a diagnosis of terminal cancer. What is the best nursing action?

What is most important for the practical nurse (PN) to include when performing pain assessment after giving an analgesic?

What factors are important in determining the level of hypoxemia that the child may have experienced during the submersion? Select all that apply.

An older female client who resides in a long-term care facility has a male friend who often visits her in the evenings. The practical nurse (PN) enters the room to administer medications and finds the couple in bed together. What action should the PN take?

The practical nurse (PN) observes a client's initial postoperative dressing and drain as seen in the picture. Which follow-up actions should the PN implement? (Select all that apply.)

The practical nurse (PN) is observing a newly hired PN who is preparing to administer a liquid medication via a client's feeding tube system using the wrong procedure. What action should the PN take?

Which statement by a mature adult client with advanced prostate cancer best indicates that he has reached a level of acceptance of his prognosis?