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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Trying not to listen to the conversation does not address the issue of confidentiality breach or protect the client's privacy.
B. Writing an incident report might be necessary, but the immediate action should be to stop the conversation to protect the client's confidentiality.
C. Approaching the individuals involved and asking them to stop is the most appropriate and immediate action to protect the client's privacy and confidentiality.
D. Telling the client about the UAP's concern might not be suitable without context or proper consent, and it might not address the confidentiality breach.
Correct Answer is B
Explanation
A. Asking about the bowel sterilization prescription isn't directly related to the client's concern about the visibility of the surgical opening.
B. Reviewing the client's expectations regarding elimination after surgery helps address the client's concerns about the surgical opening and ensures proper education and understanding.
C. Verifying the NPO status is important for surgery preparation but doesn’t address the client's specific concern.
D. Understanding if this is the client's first indwelling catheter doesn’t directly address the immediate concern of the client regarding the visibility of the surgical opening.
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