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 C
Explanation
Choice A rationale
While lean beef, salads, and baked potatoes can be part of a balanced diet, they do not specifically target the prevention of colon and rectal cancers. Red meat, in particular, has been associated with an increased risk of colorectal cancer.
Choice B rationale
Potatoes, low-fat breads, and applesauce can be part of a balanced diet, but they do not specifically target the prevention of colon and rectal cancers. A diet rich in whole grains, fruits, and vegetables is more beneficial.
Choice C rationale
A diet rich in oatmeal, raisins, and fruit with skin is high in fiber and antioxidants, which can help reduce the risk of colon and rectal cancers. This is especially important for clients with a strong family history of these cancers.
Choice D rationale
Chicken, rice, and wheat products can be part of a balanced diet, but they do not specifically target the prevention of colon and rectal cancers. A diet rich in whole grains, fruits, and vegetables is more beneficial.
Correct Answer is A
Explanation
Choice A rationale
As with, a lumbar puncture is the primary diagnostic procedure for suspected bacterial meningitis. The other choices, while useful for detecting other conditions, are not as definitive for diagnosing bacterial meningitis.
Choice B rationale
As mentioned in the rationale for, Choice B, skull radiography is not typically used to diagnose bacterial meningitis.
Choice C rationale
As mentioned in the rationale for, Choice C, an MRI can provide detailed images of the brain and surrounding tissues, but it is not the primary tool for diagnosing bacterial meningitis.
Choice D rationale
As mentioned in the rationale for, Choice D, a CT scan can detect abnormalities in the brain, but it cannot definitively diagnose bacterial meningitis.
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