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 D
Explanation
The correct answer is D. The nurse should measure the client's vital signs first to assess for any injuries or complications from the fall, such as bleeding, shock, or head trauma. The nurse should then notify the provider and document the fall in the client's medical record. Completing an incident report is also important, but it is not the first action that the nurse should take.
Correct Answer is A
Explanation
The correct answer is Choice a.
Choice a rationale: The nurse should obtain the specimen immediately upon the client waking up, as sputum from deep in the lungs is usually more easily collected at this time. Sputum collected upon waking up is more likely to contain secretions from the lower respiratory tract, providing a better sample for tuberculosis diagnosis. This timing maximizes the chance of detecting the bacteria.
Choice b rationale: Choice b is incorrect because the typical volume of sputum needed for testing is about 1 teaspoon (5 mL), not 15 to 20 mL. Collecting such a large volume could be challenging for the client and unnecessary for diagnostic purposes.
Choice c rationale: Choice c is incorrect because while gloves should be worn, they do not need to be sterile, just clean. The use of clean gloves is sufficient to prevent contamination during specimen collection, and sterile gloves are not required for this procedure.
Choice d rationale: Choice d is incorrect because it’s important to try to collect the specimen as soon as possible, not wait a full day. Delaying collection for a day could result in a missed opportunity to diagnose tuberculosis and initiate appropriate treatment promptly. Collecting the specimen promptly maximizes the accuracy of diagnostic testing and facilitates timely intervention for the client's health.
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