A nurse is assisting with the admission of an older adult client. Which of the following subjective findings suggests that the client may have cataracts?

The nurse should allow the family as much time as they want with the client who has just died. This promotes comfort for the family and allows them to say goodbye to their loved one.

a) Using paper tape to hold the client's eyelids open is not appropriate and can be distressing for the family.

b) Placing the client in a supine position is not necessary and may not be comfortable for the client.

c) Avoiding repeating information about the client's death is not helpful. The nurse should provide clear and honest information to the family and answer any questions they may have.

The correct answers are a. Document urine color, b. Monitor the client for reports of bladder spasms, and

c. Check the drainage tubing for obstructions.

a. Documenting urine color is important to monitor for any changes that may indicate complications or issues with the bladder irrigation. It helps identify any bleeding or clot formation.

b. Monitoring the client for reports of bladder spasms is crucial as bladder spasms can indicate irritation or obstruction in the urinary system. Prompt intervention can be provided to alleviate discomfort and prevent complications.

c. Checking the drainage tubing for obstructions is essential to ensure proper flow of the bladder irrigation solution. Obstructions in the tubing can lead to inadequate irrigation, which can affect the effectiveness of the procedure and potentially lead to complications.

d. Maintaining the client in a left side-lying position is not specifically indicated for continuous bladder irrigation after a transurethral resection of the prostate. The client's position should be based on their comfort and overall condition, and there is no specific requirement for a left side-lying position in this context.

e. Using clean technique for intermitent irrigation is not appropriate for continuous bladder irrigation. Continuous bladder irrigation requires aseptic technique to reduce the risk of infection and contamination.

By performing these actions, the nurse ensures proper monitoring, documentation, and maintenance of the bladder irrigation system, promoting the client's safety and well-being.