The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which is the best initial nursing action?

Choice A reason: Reports of a bad taste in the mouth can be associated with various conditions, including metabolic imbalances, but it is not typically an immediate concern in the context of AKI.

Choice B reason: Low concentrated urine output (oliguria) is a common finding in AKI and indicates decreased kidney function. While it is an important assessment finding, it does not usually require immediate intervention compared to signs of severe complications.

Choice C reason: Dyspnea (difficulty breathing) and sinus tachycardia (rapid heart rate) can indicate fluid overload or pulmonary edema, which are serious complications of AKI. These symptoms require immediate intervention to prevent respiratory distress and potential cardiac complications.

Choice D reason: A productive cough and fever may suggest an infection, which is important to address but not necessarily an immediate life-threatening issue compared to dyspnea and tachycardia in the context of AKI.

Choice A reason: Administering a PRN dose of an antispasmodic agent can help relieve bladder spasms that often occur after TURP, but it does not address the immediate issue of blood clots blocking the drainage tubing. The primary concern is to ensure the patency of the catheter and proper drainage.

Choice B reason: Increasing the flow of the bladder irrigation is the best initial action. By increasing the flow, the nurse can help flush out the blood clots from the drainage tubing and ensure that the catheter remains patent. This action directly addresses the problem of blocked drainage and prevents further complications.

Choice C reason: Measuring the client's intake and output is important for overall monitoring, but it does not directly address the immediate concern of blood clots in the drainage tubing. Ensuring proper drainage is crucial to prevent complications such as bladder distention and further bleeding.

Choice D reason: Providing additional oral fluid intake is beneficial for maintaining hydration and promoting urine output, but it does not solve the problem of blood clots in the drainage tubing. The primary focus should be on ensuring the catheter's patency through irrigation.