A nurse is caring for a client who has Alzheimer's disease and is confused. Which of the following actions should the nurse take?

Choice A reason: Adding the amount of bladder irrigation to the total output is incorrect. Instead, the nurse should subtract the amount of irrigation solution instilled from the total output to accurately measure the client's urine output.

Choice B reason: The correct answer is b because using sterile technique when preparing the irrigation solution is crucial to prevent introducing infections into the bladder or urinary tract during the continuous bladder irrigation process.

Choice C reason: The correct answer is c because ensuring the drainage tubing is patent and without obstruction is essential to maintain effective bladder irrigation and prevent complications such as bladder distention and clot formation.

Choice D reason: The correct answer is d because if the client reports a continual need to void, it may indicate that the irrigation is not functioning properly, and the surgeon should be contacted to assess the situation and make necessary adjustments.

Choice E reason: The correct answer is e because bright red urine or the presence of large clots can indicate active bleeding, which requires prompt notification of the surgeon for further evaluation and intervention.

Choice A reason: Telling the partner to call the nurse to push the button is not appropriate. PCA is designed to allow the client to self-administer pain medication based on their own perception of pain. Only the client should press the button to avoid the risk of over-sedation and respiratory depression.

Choice B reason: Encouraging the partner to press the button while the client is asleep can lead to over-medication and serious complications such as respiratory depression.

Choice C reason: Asking the partner why they think more medication is needed when the client is asleep does not address the underlying issue of inappropriate use of the PCA pump.

Choice D reason: The correct answer is d because the client should be the one to decide when more medication is needed. This ensures that the client receives the appropriate amount of pain relief based on their individual needs and prevents the risk of over-sedation.