A nurse is caring for a client who is scheduled for surgery. The client states, "I have decided not to have the surgery." Which of the following responses should the nurse make to the client?

A. "Wear a pair of disposable briefs at bedtime.": Using briefs may provide protection against leakage but does not address the underlying bladder control issue. Bladder retraining focuses on strengthening muscles and establishing voiding schedules.

B. "Limit oral fluid intake to 1,000 milliliters per day.": Restricting fluids can lead to dehydration and urinary tract infections. Adequate hydration is important for bladder health, and fluid restriction is not a recommended strategy for retraining.

C. "Practice pelvic-floor exercises regularly.": Pelvic-floor (Kegel) exercises strengthen the muscles that support bladder control, improve continence, and are a key component of bladder retraining programs. Consistent practice enhances effectiveness over time.

D. "Drink 8 ounces of citrus juice per day.": Citrus juice is not necessary for bladder retraining and may irritate the bladder in some individuals. Dietary recommendations should focus on overall hydration and bladder-friendly fluids rather than specific juices.

Rationale for correct choices:

• Obtain IV access: The client has hypotension (BP 90/50 mm Hg), tachycardia (HR 118/min), and significant anemia (Hgb 9.1 g/dL, Hct 27%), all of which suggest possible active gastrointestinal bleeding. Establishing IV access is a priority to allow rapid fluid resuscitation or blood product administration as needed.
• Prepare for a blood transfusion: Given the positive hemoccult stool, anemia, and vital sign changes, the client may require a blood transfusion to restore hemodynamic stability and oxygen-carrying capacity. Preparing for transfusion ensures timely intervention in case of worsening blood loss.

Rationale for incorrect choices:

• Call the surgical suite to notify that the client is arriving STAT: While the client is scheduled for endoscopy, immediate stabilization takes priority over notifying the surgical suite. The client’s hemodynamic status must be addressed first to prevent deterioration.
• Recheck the client's oxygen saturation: The client’s oxygen saturation is 98% on room air, which is within normal limits. Rechecking is not immediately necessary and does not address the urgent need for stabilization.
• Place the client in a supine position with feet elevated: Although elevating the feet can help improve perfusion temporarily, it does not treat the underlying anemia or hypotension and is less urgent than establishing IV access and preparing for transfusion.
• Offer oral fluids: Oral intake is contraindicated in a client at risk for endoscopy and possible GI bleeding. Fluids could increase the risk of aspiration and do not address hemodynamic instability.
• Administer PRN antacids: Antacids may provide minor symptom relief but do not treat active blood loss or stabilize the client before endoscopy.
• Document vital signs: Documentation is important but secondary to immediate interventions that address the client’s hypotension and potential hemorrhage.