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: An open fracture, while needing medical attention, is not immediately life-threatening. The client's condition is stable enough to wait while more critical cases are attended to.

Choice B reason: A penetrating head injury with seizures is a critical condition. However, ensuring a patent airway takes precedence in emergency situations. This client's seizures indicate serious brain injury, but the immediate threat to life, such as airway obstruction, must be prioritized.

Choice C reason: Severe respiratory stridor and a deviated trachea indicate a life-threatening airway obstruction. This client needs immediate attention to secure the airway and prevent respiratory failure. This is the highest priority because without a clear airway, the client will not survive long enough to benefit from other interventions.

Choice D reason: A partial-thickness burn, although painful and requiring treatment, is not immediately life-threatening. This client can safely wait while those with more critical needs are attended to.