A client arrives at the medical-surgical unit 4 hours after a transurethral resection of the prostate. A triple-lumen catheter for continuous bladder irrigation with normal saline is infusing and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag.

Which action should the nurse take?

Decrease the flow rate.

Irrigate the catheter manually.

Discontinue infusing solution.

Monitor catheter drainage.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Decreasing the flow rate of the irrigation solution is not the best action in this situation. The presence of blood clots in the tubing and collection bag indicates that the client may be experiencing clot retention, which can lead to urinary obstruction. Decreasing the flow rate may not provide sufficient force to dislodge clots from the catheter, which could exacerbate the problem.
Choice B rationale
Manually irrigating the catheter is the most appropriate action when blood clots are observed in the tubing and collection bag. Clots can obstruct the catheter and disrupt the continuous bladder irrigation, leading to urinary retention and increased discomfort for the client. Manual irrigation can help dislodge and remove these clots, ensuring the patency of the catheter and the effectiveness of the irrigation.
Choice C rationale
Discontinuing the infusion of the irrigation solution is not the best action in this situation. The purpose of continuous bladder irrigation after a transurethral resection of the prostate is to prevent clot formation and retention by continuously flushing the bladder. Discontinuing the infusion could lead to the formation of more clots, potentially causing urinary obstruction.
Choice D rationale
While monitoring catheter drainage is an important part of postoperative care, it is not the most appropriate action in this situation. The presence of blood clots in the tubing and collection bag indicates a potential problem that requires immediate intervention. Simply monitoring the situation without taking action to resolve it could lead to urinary obstruction and increased discomfort for the client.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Choice A rationale
Exclusively consuming lactose-free dairy products is not a specific characteristic of the DASH diet. While the DASH diet recommends low-fat or fat-free dairy products, it does not specifically require them to be lactose-free.
Choice B rationale
Meticulously cleaning and peeling all fresh fruits and vegetables is a good practice for food safety, but it is not specific to the DASH diet.
Choice C rationale
Enjoying fat-free yogurt as an occasional snack aligns with the DASH diet’s emphasis on low-fat dairy products.
Choice D rationale
Eliminating grains from the diet is not recommended in the DASH diet. On the contrary, the DASH diet encourages the consumption of whole grains.

A. Explain the need to limit intake of oral fluids to reduce client discomfort. B. Teach the client techniques for performing intermittent catheterization. C. Remind the client to practice pelvic floor (Kegel) exercises regularly. D. Provide a bedside commode for immediate use in the client’s room.

Correct Answer is B

Explanation

Choice A rationale
Limiting intake of oral fluids is not typically recommended for a client with urinary retention related to sensorimotor deficits in multiple sclerosis. Adequate hydration is important for overall health and can help prevent urinary tract infections14.
Choice B rationale
Teaching the client techniques for performing intermittent catheterization is a common and effective strategy for managing urinary retention in multiple sclerosis. This can help the client maintain independence and improve quality of life14.
Choice C rationale
While pelvic floor (Kegel) exercises can help strengthen the muscles involved in urination, they may not be sufficient to manage urinary retention in a client with multiple sclerosis.
Intermittent catheterization (Choice B) is often more effective14.
Choice D rationale
Providing a bedside commode can be helpful for a client with mobility issues, but it does not directly address the issue of urinary retention in multiple sclerosis14.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a patient’s understanding of the DASH (Dietary Approaches to Stop Hypertension) diet. Which patient behavior suggests adherence to this diet?

Correct Answer is C

Explanation

A client with multiple sclerosis has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client’s plan of care?

Correct Answer is B

Explanation

The parent of an adolescent tells the clinic nurse, “My child has athlete’s foot. I have been applying triple antibiotic ointment for two days, but there has been no improvement.”. Which instruction should the nurse provide?

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The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis. Which diagnostic procedure should the nurse prepare the client for the healthcare provider?

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