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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Encouraging a warm sleeping environment might exacerbate itching for some individuals.
Keeping fingernails trimmed short prevents skin damage from scratching and reduces the risk of infection.
Using skin lubricants can often alleviate pruritus by moisturizing the skin.
Tub baths with certain additives can exacerbate itching, but not all types of tub baths need to be avoided.
Correct Answer is B
Explanation
A. Asking about the bowel sterilization prescription doesn't address the client's concern regarding the visibility of the surgical opening.
B. Reviewing the client's expectations after surgery could address the client's query about the visibility of the surgical opening and offer information regarding elimination.
C. Verifying the NPO status is important for surgery preparation but doesn’t directly address the client's specific concern.
D. Determining if this is the first indwelling catheter doesn’t directly address the client's immediate concern regarding the surgical opening.
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