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 B
Explanation
A. Eating green leafy vegetables high in vitamin K can interfere with the action of certain anticoagulants; however, it's not the primary instruction given post-cardioversion.
B. Using an electric razor helps prevent cuts and bleeding, which can be more significant due to anticoagulant therapy.
C. Doubling the dose after a missed dose is incorrect and potentially dangerous.
D. Taking the medication before meals might not be the primary concern regarding anticoagulant use.
Correct Answer is C
Explanation
A. Write an incident report about the bruises on the infant. - These areas might not be bruises; hence, writing an incident report without accurate information could be premature.
B. Review the labor and delivery record for birth trauma. - While important, it might not directly relate to the observed bluish-black areas.
C. Record the size and location of the areas in the infant's chart. - Documenting the observations is essential for tracking changes and informing other healthcare providers.
D. Notify the pediatrician of a possible bleeding problem with the infant. - Without further assessment, assuming a bleeding problem might be premature and unnecessarily alarming.
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