A nurse is caring for a client who has lung cancer. The client tells the nurse they do not want to be resuscitated in the event of a cardiac arrest. Which of the following statements should the nurse make?

Choice A reason: Dark red urine signals active bleeding post-TURP, beyond expected light pink. It may indicate hemorrhage, requiring urgent provider intervention to prevent complications.

Choice B reason: 300 mL over 8 hr is adequate output post-TURP, not alarming. It aligns with expected bladder irrigation effects, needing no immediate report.

Choice C reason: Small clots are normal post-TURP as the prostate heals. Only large or persistent clots warrant concern, so this is an expected finding.

Choice D reason: Frequent urination urge is common post-TURP from bladder irritation. It’s not critical unless paired with obstruction, so it doesn’t need reporting.

Choice A reason: Applying suction while inserting risks trauma to nasal mucosa, as continuous pressure can tear delicate tissues or cause bleeding. Proper technique involves inserting without suction, then applying it on withdrawal to safely remove secretions, minimizing injury and ensuring effective clearance without damaging the airway lining.

Choice B reason: Intermittent suction for 30 seconds exceeds safe limits; guidelines recommend 10-15 seconds to avoid hypoxia. Prolonged suction depletes oxygen in the airway, especially in nasopharyngeal suctioning, where ventilation is obstructed, risking respiratory distress or cardiac complications in an adult client with compromised breathing.

Choice C reason: Inserting the catheter 10 cm (4 in) is too shallow for nasopharyngeal suctioning in adults, where 16-20 cm reaches the pharynx. Insufficient depth fails to clear secretions effectively, leaving mucus in lower airways, potentially worsening obstruction or infection, as the catheter must target the secretion source accurately.

Choice D reason: Waiting 1 minute between attempts allows oxygen levels to stabilize, preventing hypoxia during nasopharyngeal suctioning. This interval ensures the client reoxygenates after airway occlusion, reducing risks of desaturation or arrhythmia, aligning with safe practice to maintain respiratory stability while clearing mucus effectively in adults.