A client is receiving a postoperative continuous bladder irrigation via a three-way indwelling catheter for a transurethral resection of the prostate (TURP). Twelve hours after the surgery, the practical nurse (PN) is monitoring the urine in the catheter's bedside drainage unit and observes that the drainage is a thick red fluid with clots. What action should the PN implement?
Check for kinks in the drainage tubing.
Observe the drainage again in one hour.
Report the finding to the charge nurse.
Stop the irrigation solution immediately
The Correct Answer is C
A. Checking for kinks in the drainage tubing might be a part of troubleshooting, but the observed clots and thick red fluid require immediate attention, so informing the charge nurse is the priority.
B. Delaying assessment for another hour could potentially exacerbate the issue if there's a problem with the irrigation or if the client's condition worsens.
C. Reporting the finding to the charge nurse is crucial as it indicates potential complications such as bleeding or clot formation that need immediate intervention.
D. Immediately stopping the irrigation solution without proper assessment and guidance could lead to complications and isn't the initial action warranted in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Checking the perineum for changes in "show" or discharge is important for monitoring labor progress, but it does not directly address the client's immediate need to empty her bladder. This action would be more relevant if there were signs of labor progression or complications.
B. Reviewing the fetal heart rate pattern is crucial for assessing fetal well-being, but it does not resolve the client's discomfort from a full bladder. While important, it does not address the specific request made by the client.
C. Obtain a straight catheter kit to empty her bladder is unnecessary since the client can ambulate and has expressed the desire to void. Catheterization is typically reserved for clients unable to void independently or when the bladder is distended and interfering with labor progression.
D. Assist the client up to the bathroom is the correct action. Allowing the client to empty her bladder helps facilitate labor progression, as a full bladder can impede fetal descent. Since the vaginal exam is unchanged and the client is stable, ambulation to the bathroom is safe and appropriate. Additionally, this action supports the client’s autonomy and comfort during labor.
Correct Answer is ["B","C"]
Explanation
A. The wound is not inflamed, but rather discharging excessively. The PN should document the amount and color of the drainage, the size and location of the wound, and any signs of infection or complications.
B. The dressing needs to be changed as soon as possible to prevent infection and further blood loss. The charge nurse can also assess the need for additional interventions, such as suturing, hemostasis, or transfusion.
C. Compressing the device creates a vacuum that helps drain the fluid from the wound. The PN should squeeze the device until it is about half full, then close the tab securely.
D. Clamping the tubing can cause a backup of fluid in the wound, which can increase the risk of infection and impair healing. The PN should never clamp the tubing unless instructed by the provider.
E. Removing the device can cause more bleeding and disrupt the healing process. The PN should only remove the device when ordered by the provider or when it is no longer needed.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.