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: Administering PRN pain medication can help manage the client's discomfort, but it does not address the underlying cause of the pain. It is essential to assess and identify the source of the pain before administering pain relief. Providing pain medication without a thorough assessment may mask symptoms of a serious underlying issue.

Choice B reason: Observing the leg for swelling is important, as swelling can indicate complications such as compartment syndrome or infection. However, it is not the first action the nurse should take. While swelling is a significant sign, assessing blood flow to the extremity is more critical and should be prioritized.

Choice C reason: Assessing peripheral pulses is the correct first intervention. The presence of foot pain in a client with an external fixation device for a fractured femur could indicate compromised blood flow to the lower extremity. Assessing the peripheral pulses will help determine if there is adequate circulation. If pulses are weak or absent, it may suggest a serious vascular issue that requires immediate intervention to prevent further complications such as tissue ischemia or necrosis.

Choice D reason: Auscultating blood pressure is a routine assessment but does not directly address the immediate concern of left foot pain in this scenario. Blood pressure assessment is important for overall health monitoring but is not the priority when dealing with a possible vascular complication in the affected limb. Ensuring adequate blood flow to the extremity takes precedence.

Choice A reason: Notifying the surgical team to cancel the surgery is premature without confirming the pregnancy status. While it is critical to consider the possibility of pregnancy before surgery, the decision to cancel should be based on confirmed information rather than a possibility.

Choice B reason: Performing a bedside pregnancy test is the most appropriate immediate intervention. This test can provide rapid confirmation of pregnancy status. If the client is pregnant, the surgical team can then evaluate the risks and benefits of proceeding with or postponing the surgery. Immediate confirmation helps guide clinical decision-making and ensures the safety of both the client and the potential fetus.

Choice C reason: Continuing with surgery as scheduled without confirming the pregnancy status is not appropriate. Anesthesia and surgical procedures can pose risks to a pregnant client and the fetus. It is essential to verify the pregnancy status to make an informed decision about the safety and necessity of the surgery.

Choice D reason: Calculating gestation from the last menstrual cycle can provide an estimate of the pregnancy duration, but it does not confirm pregnancy. A bedside pregnancy test should be performed first to confirm whether the client is pregnant before considering gestational age. This information can then be used to further assess the situation and plan appropriate care.