A nurse is assessing a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate 4 hr ago.
The nurse notes pink-tinged urine in the drainage bag.
Which of the following actions should the nurse take?
Maintain the irrigation solution rate.
Replace the indwelling urinary catheter.
Perform the Credé's maneuver.
Warm the irrigation solution.
The Correct Answer is A
Choice A rationale:
Maintaining the irrigation solution rate is appropriate in this situation. Pink-tinged urine in the drainage bag indicates the presence of blood, which is expected after a transurethral resection of the prostate. However, if the bleeding becomes excessive, the healthcare provider should be notified. Adjusting the irrigation solution rate might be necessary based on the provider's orders, but abruptly changing the rate without medical direction could lead to complications.
Choice B rationale:
Replacing the indwelling urinary catheter is not necessary solely based on the presence of pink-tinged urine. It is essential to assess the patient's overall condition and the extent of bleeding before considering catheter replacement. Catheter replacement without a valid reason can increase the risk of infection and discomfort for the patient.
Choice C rationale:
Performing the Credé's maneuver involves manual compression of the bladder to assist with urine elimination. This maneuver is not indicated in this situation and could potentially cause harm or disrupt the continuous bladder irrigation. It is essential to follow evidence-based practices and avoid interventions that are not appropriate for the patient's condition.
Choice D rationale:
Warming the irrigation solution is not relevant to the situation described. The presence of pink-tinged urine suggests bleeding, which requires careful monitoring and appropriate medical intervention. Warming the solution does not address the underlying cause of the bleeding and should not be the nurse's primary concern in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"B"}}
Explanation
The assessment findings that are consistent with mastitis are: Chills Temperature Painful, tender breast The assessment findings that are consistent with endometritis are: Chills Temperature Foulsmelling lochia Mastitis is an inflammation of the breast tissue that can lead to infection. It is usually caused by a blocked milk duct or bacteria entering the breast through a cracked nipple. Mastitis can cause symptoms such as fever, chills, headache, body aches, and redness, swelling, and pain in the affected breast. Mastitis is usually treated with antibiotics and pain relievers. It is important to continue breastfeeding or pumping to empty the breast and prevent further engorgement. Endometritis is an inflammation of the inner lining of the uterus (endometrium) that can lead to infection. It is usually caused by bacteria entering the uterus during childbirth, miscarriage, abortion, or insertion of an intrauterine device (IUD). Endometritis can cause symptoms such as fever, chills, lower abdominal pain, foul-smelling vaginal discharge (lochia), and uterine tenderness. Endometritis is usually treated with antibiotics and pain relievers. It is important to seek medical attention if symptoms persist or worsen .
Correct Answer is A
Explanation
Choice A rationale:
Documenting the desire to be an organ donor in writing is a legal requirement and ensures that the individual's wishes are respected after their passing. It also provides clear guidance to healthcare providers and family members about the individual's decision.
Choice B rationale:
There is no specific age requirement to become an organ donor. People of various ages can register as organ donors, and eligibility often depends on the condition of the organs at the time of death.
Choice C rationale:
Once someone is listed as an organ donor, their name can be removed if they change their mind. It's essential for individuals to inform their family members about their decision and ensure their wishes are respected.
Choice D rationale:
The nurse can indeed be a witness for the consent to donate. Being a witness ensures the authenticity of the individual's decision to become an organ donor and can be helpful in legal and ethical contexts.
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.