The first time that a client voids after cystoscopy, the nurse observes pink-tinged urine. What is the appropriate nursing response?
Document normal findings
Contact the Rapid Response Team
Promptly notify the health care provider
Restrict fluids
The Correct Answer is A
A. Document normal findings: Pink-tinged urine is expected after a cystoscopy due to minor trauma to the urethra or bladder during the procedure.
B. Contact the Rapid Response Team: Pink-tinged urine does not indicate a medical emergency requiring the Rapid Response Team.
C. Promptly notify the healthcare provider: This finding does not require immediate notification unless accompanied by significant bleeding, clots, or other abnormal symptoms.
D. Restrict fluids: Increasing fluid intake helps flush the urinary tract and reduce irritation after a cystoscopy.
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Related Questions
Correct Answer is C
Explanation
A. Including ureteral output with the bladder output: Ureteral catheter output should be measured separately to ensure accurate monitoring of each source.
B. Early ambulation: While ambulation is beneficial for overall recovery, the priority is ensuring the catheter is patent and urine is draining freely.
C. Assessing for patency: Ensuring the ureteral catheter is patent and draining prevents complications such as obstruction, hydronephrosis, or infection.
D. Irrigating the catheter regularly: Ureteral catheters are not routinely irrigated, as improper irrigation can damage the ureters or kidneys.
Correct Answer is A
Explanation
A. Hyperkalemia: Hyperkalemia is the most life-threatening effect of renal failure because elevated potassium levels can cause dangerous cardiac arrhythmias or cardiac arrest.
B. Hypokalemia: Hypokalemia is not commonly associated with renal failure and is less immediately life-threatening than hyperkalemia.
C. Hypernatremia: While fluid imbalances can lead to hypernatremia, it is less critical than hyperkalemia in renal failure.
D. Hyponatremia: Although hyponatremia can occur in renal failure, its effects are typically less acutely life-threatening than hyperkalemia.
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