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 ["B","C","D"]
Explanation
These are the information that the PN should obtain prior to administering pain medication to an adult postoperative client because they help to assess the client's current pain level, response to previous medication, and need for further intervention. The PN should also document this information in the medical record and report any changes or concerns.
A. Height and weight of client prior to admission are not relevant for administering pain medication and may not affect the dosage or route of the medication.
E. History of pain medication use during the past year is not relevant for administering pain medication and may not indicate the client's tolerance or preference for the medication.
Correct Answer is C
Explanation
Instruct the UAP to lower the bed for safety.
This is the best action for the PN to take because it ensures the client's safety and prevents potential falls or injuries. The PN should also educate the UAP on the importance of lowering the bed when providing care to a bedfast client.
A. Assuming care of the client immediately is not necessary and may undermine the UAP's confidence and competence.
B. Remaining in the room to supervise the UAP is not appropriate and may interfere with the client's privacy and dignity.
D. Determining if the UAP would like assistance is not a priority and may not address the safety issue.
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