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.

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Correct Answer is C

Explanation

Guillain-Barre syndrome is a disorder in which the body’s immune system attacks the nerves, causing weakness and tingling, usually starting in the legs and hands. A loss of sensation, especially at the T-8 spinal level, could indicate that the syndrome is progressing, potentially leading to paralysis. This would require immediate intervention by the nurse to prevent further complications.

A. Notify the healthcare provider of the client’s medication history. B. Ensure that the potential for bleeding is explained to the client. C. Have the client sign the surgical and transfusion permits. D. Observe the heparin injection sites for signs of bruising.

Correct Answer is A

Explanation

Notifying the healthcare provider of the client’s medication history is the priority nursing action. Heparin is an anticoagulant, which increases the risk of bleeding. The healthcare provider needs this information to make appropriate decisions about the client’s surgical plan and postoperative care.

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Naxlex Comprehensive Predictor Exams

While providing care for a patient with Guillain-Barre syndrome, the nurse conducts a neurological assessment every four hours. Which finding from the assessment requires immediate intervention by the nurse?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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