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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Latent hepatitis C is not a contraindication for peritoneal dialysis. While it may require additional monitoring and treatment, it does not prevent a patient from receiving peritoneal dialysis.
Choice B rationale
Crohn’s disease with colectomy is a contraindication for peritoneal dialysis. The presence of extensive adhesions and fibrosis from the surgery can make the peritoneum unsuitable for dialysis.
Choice C rationale
A history of nephrotic syndrome is not a contraindication for peritoneal dialysis. Nephrotic syndrome is a kidney disorder, and peritoneal dialysis can be used as a treatment for patients with kidney disease.
Choice D rationale
Type 2 diabetes mellitus is not a contraindication for peritoneal dialysis. Many patients with diabetes undergo peritoneal dialysis. However, careful monitoring of blood glucose levels is necessary, as the dialysis solution used in peritoneal dialysis contains glucose.
Correct Answer is B
Explanation
Choice A rationale
Similar to, while spicy foods can irritate the urinary tract, they do not have a direct impact on the care and management of an indwelling urinary catheter after a TURP3.
Choice B rationale
As in, drinking 3 liters of water each day is important as it helps flush the bladder and reduce the risk of urinary tract infections, which are a common complication after a TURP3.
Choice C rationale
As in, clamping the catheter is not typically recommended as it can lead to urinary retention and increase the risk of urinary tract infections.
Choice D rationale
As in, avoiding driving for 2 weeks is a general recommendation after any major surgery to allow the body time to heal, but it does not directly relate to the care of an indwelling urinary catheter.
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