A client is receiving 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.
Report the finding to the charge nurse.
Stop the irrigation solution immediately.
Observe the drainage again in one hour.
The Correct Answer is B
The correct answer is Choice B. Report the finding to the charge nurse. Choice A rationale:
Checking for kinks in the drainage tubing is an important troubleshooting step if there is a sudden decrease or absence of urine output. However, in this case, the PN's concern is the presence of thick red fluid with clots in the urine drainage. This finding indicates potential bleeding, which requires immediate attention and reporting.
Choice B rationale:
Reporting the finding to the charge nurse is the correct action. The presence of thick red fluid with clots in the urine suggests significant bleeding after the transurethral resection of the prostate (TURP) surgery. It is crucial to inform the charge nurse or the healthcare provider promptly so that appropriate interventions can be initiated to address the bleeding.
Choice C rationale:
Stopping the irrigation solution immediately may not be within the PN's scope of practice unless explicitly instructed by the healthcare provider. Moreover, abruptly stopping the irrigation may lead to complications, and it is essential to involve the charge nurse or healthcare provider in making this decision.
Choice D rationale:
Observing the drainage again in one hour is not appropriate in this situation. The presence of thick red fluid with clots in the urine drainage is an urgent concern that requires immediate action, not a wait-and-see approach.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D. Electrolytes.
Choice A rationale: The white blood cell count (WBC) is typically reviewed for signs of infection or inflammation, but it is not directly related to numbness and tingling.
Choice B rationale: Hematocrit levels assess the proportion of red blood cells in the blood, which are not commonly associated with numbness and tingling.
Choice C rationale: Albumin and protein levels are important for nutritional status and overall health but are not directly associated with numbness and tingling.
Choice D rationale: Electrolytes are crucial for nerve function and muscle contractions. Abnormal levels of electrolytes (such as calcium, potassium, or sodium) can lead to symptoms like numbness and tingling in the extremities.
Correct Answer is A
Explanation
Glaucoma is a group of eye diseases that damage the optic nerve and cause vision loss. It is often associated with increased intraocular pressure, which can compress the nerve fibers and reduce blood flow to the retina. The most common type of glaucoma, open-angle glaucoma, causes gradual loss of peripheral vision.
The other options are not correct because:
- Macular edema is a condition that causes swelling and fluid accumulation in the macula, the central part of the retina that is responsible for sharp and detailed vision. It can cause blurred or distorted vision, but it does not affect the optic nerve or the peripheral vision.
- Cataract is a condition that causes clouding of the lens, which is the transparent structure that focuses light onto the retina. It can cause blurred, dim, or yellowed vision, but it does not affect the optic nerve or the intraocular pressure.
- Diabetic retinopathy is a complication of diabetes that damages the blood vessels in the retina and causes bleeding, leakage, or scarring. It can cause blurred, fluctuating, or darkened vision, but it does not affect the optic nerve or the intraocular pressure.
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