A nurse is caring for a client who develops a pulmonary embolism.
Which of the following interventions is the priority for the nurse to take?

Choice A rationale

Fluid retention in chronic renal failure (CRF) is primarily managed by restricting sodium and fluid intake, not by a low-protein diet. Protein intake primarily impacts nitrogenous waste production, not the homeostatic mechanisms of antidiuretic hormone and aldosterone that regulate fluid volume retention.

Choice B rationale

Protein breakdown yields nitrogenous waste products, primarily in the form of urea. In chronic renal failure, the damaged nephrons lose their capacity to efficiently filter and excrete these wastes, causing them to build up in the bloodstream, leading to symptoms of uremia and an increased BUN.

Choice C rationale

Protein does not impair potassium storage. Hyperkalemia (high potassium) is a common, life-threatening complication of chronic renal failure, often resulting from the kidney's inability to excrete potassium, especially when coupled with certain medications or high dietary intake of potassium.

Choice D rationale

High protein intake, particularly from animal sources, can contribute to calcium loss by increasing the body's acid load. The body then buffers this acid by releasing calcium from the bones, a process unrelated to calcium retention, which is often impaired in renal failure due to Vitamin D metabolism issues.

Choice A rationale

Offering oral fluids increases the overall fluid load, which is generally helpful for increasing urinary output and flushing the urinary tract; however, the client is currently experiencing zero urinary output with continuous bladder irrigation (CBI). Before adding more fluid, the immediate priority is to ensure the outflow tract is clear; otherwise, the fluid will back up into the bladder, causing distention and pain.

Choice B rationale

Notifying the provider is a necessary step if the immediate measures to restore patency fail. A period of anuria post-TURP with CBI suggests a possible clot obstruction that could lead to severe bladder distention, pain, and potential bladder rupture. However, the nurse must first independently assess and attempt to correct the most common cause (occlusion) before escalation.

Choice C rationale

Administering an analgesic may temporarily alleviate pain associated with bladder spasms or distention caused by an occluded catheter. However, addressing the underlying mechanical problem (lack of output/obstruction) is the primary concern, as pain is a symptom of the blockage, not the cause. Restoring patency prevents complications and is the immediate priority.

Choice D rationale

The absence of urinary output with continuous bladder irrigation (CBI) strongly suggests the 3-way catheter is occluded, most likely by a blood clot or tissue fragments following the TURP. The first action is to determine patency by checking for kinks and attempting to gently manually irrigate the catheter using an aseptic technique and 30-50 mL of sterile normal saline solution per protocol to dislodge the obstruction.