A client arrives to 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?
Irrigating the catheter manually.
Monitoring catheter drainage.
Discontinuing infusing solution.
Decreasing the flow rate.
The Correct Answer is B
A. Irrigating the catheter manually:
Manually irrigating the catheter without an order may disrupt the clotting process and increase the risk of bleeding. It is not a routine nursing intervention post-TURP without specific orders.
B. Monitoring catheter drainage.
It is not within the nurse's scope of practice to manually irrigate the catheter without a healthcare provider's order, especially in the context of post-TURP care. The dark, pink-tinged outflow with blood clots indicates some expected bleeding following the procedure. The nurse should closely monitor the catheter drainage for the amount, color, and presence of clots.
C. Discontinuing infusing solution:
Discontinuing the normal saline irrigation may lead to clot formation and obstruction, potentially worsening the situation. The continuous bladder irrigation is often used to prevent clot formation and maintain catheter patency post-TURP.
D. Decreasing the flow rate:
The flow rate is typically set by the healthcare provider to maintain catheter patency and prevent clot formation. Decreasing the flow rate without specific orders may not be appropriate in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Jugular vein distention:
Jugular vein distention is not typically associated with an increased risk of a stroke. It may be indicative of issues related to cardiac or fluid volume status.
B. Carotid bruit:
This is the correct answer. A carotid bruit, an abnormal sound caused by turbulent blood flow through the carotid artery, may indicate the presence of atherosclerosis and increased risk of stroke. It suggests a narrowing or blockage in the carotid artery, which can potentially lead to emboli and subsequent stroke.
C. Nuchal rigidity:
Nuchal rigidity, stiffness of the neck, is associated with conditions such as meningitis but is not a direct risk factor for a stroke.
D. Palpable cervical lymph node:
Palpable cervical lymph nodes may be indicative of infection or inflammation in the head and neck region but are not directly associated with an increased risk of a stroke.
Correct Answer is D
Explanation
A. Jogs more frequently than usual daily routine:
Exercise, including jogging, is generally not associated with an increased risk of renal calculi. In fact, regular physical activity can have health benefits.
B. Eats a vegetarian diet with cheese 2 to 3 times a day:
A vegetarian diet alone is not necessarily a risk factor for renal calculi. However, the inclusion of high-oxalate foods, such as certain types of cheese, may contribute to the formation of kidney stones.
C. Experiences additional stress since adopting a child:
Stress is not a direct risk factor for renal calculi. However, certain dietary and lifestyle factors play a more significant role in stone formation.
D. Drinks several bottles of carbonated water daily:
This is the correct answer. Consuming large amounts of carbonated water, especially if it is high in phosphoric acid, can contribute to the formation of kidney stones. Carbonated beverages may increase the excretion of calcium in the urine, potentially leading to stone formation.
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