The nurse is caring for different 4 clients. Which of the following client assessments would cause the most concern for the nurse?

Choice A reason: Opioids slow gastrointestinal motility by binding to mu-opioid receptors in the gut, reducing peristalsis and increasing water absorption, leading to constipation. This is a common, predictable side effect requiring proactive monitoring to prevent discomfort or complications like impaction.

Choice B reason: Diarrhea is less likely with opioids, which typically cause constipation. While diarrhea could indicate an unrelated issue, it is not a primary concern associated with opioid use, making it a lower priority for assessment.

Choice C reason: Hemorrhoids may result from straining due to constipation but are a secondary concern. Opioids do not directly cause hemorrhoids, so assessing for constipation takes precedence to address the root cause of potential straining.

Choice D reason: Clostridium difficile infection is a risk with antibiotic use, not opioids. While opioid-induced constipation could alter gut flora indirectly, C. difficile is not a primary concern, making constipation the more immediate assessment priority.

Choice A reason: Bladder distention with tenderness indicates ineffective irrigation, suggesting obstruction or inadequate fluid flow. Continuous bladder irrigation (CBI) aims to maintain bladder patency and prevent clot formation. Distention reflects urine or clot accumulation, potentially leading to bladder injury or infection, requiring immediate intervention.

Choice B reason: Blood clots or sediment in the drainage bag suggest inadequate irrigation. CBI is designed to flush out clots and debris post-surgery to prevent obstruction. Persistent clots indicate the irrigation fluid is not effectively clearing the bladder, increasing risks of catheter blockage and urinary complications.

Choice C reason: Bright red urine turning pink indicates effective CBI. Initially, hematuria is common post-genitourinary surgery, but a lighter color suggests the irrigation is diluting blood and clearing clots, maintaining catheter patency and promoting healing by reducing bladder irritation and obstruction risks.

Choice D reason: Output smaller than the instilled amount suggests fluid retention or leakage, indicating ineffective irrigation. CBI requires output to equal or exceed input to ensure bladder flushing and catheter patency. Reduced output may signal obstruction or absorption, risking bladder overdistention or systemic fluid imbalance.