A nurse is caring for a client who is experiencing status epilepticus. Which of the following medications should the nurse expect to administer?

A. Perform the Credés maneuver: The Credés maneuver involves applying manual pressure over the bladder to promote voiding. This technique is contraindicated in clients with continuous bladder irrigation post-TURP, as it can disrupt the surgical site and increase the risk of bleeding or trauma.

B. Maintain the irrigation solution rate: Pink-tinged urine is an expected finding in the immediate postoperative period following TURP. Maintaining the prescribed irrigation rate helps prevent catheter obstruction from clots, ensures continuous drainage, and reduces the risk of bladder distention and further bleeding.

C. Replace the indwelling urinary catheter: Catheter replacement is unnecessary when urine is draining and pink-tinged, indicating minor bleeding rather than obstruction or malfunction. Routine replacement could introduce infection and trauma.

D. Warm the irrigation solution: Warming the solution is generally not required unless the client experiences discomfort from cold fluid. It does not address the normal postoperative pink-tinged urine and does not influence clot prevention.

Rationale for correct choices

• Pneumonia: The child is at risk for postoperative pneumonia due to shallow breathing and refusal to use the incentive spirometer. Postoperative pain can limit deep breathing, decreasing alveolar expansion and promoting secretion retention. This immobility of airways increases the likelihood of atelectasis, which can progress to pneumonia if preventive measures are not implemented.

• Shallow breathing: Shallow respirations reduce tidal volume and limit lung expansion, contributing to alveolar collapse and secretion accumulation. This is a common postoperative risk, particularly in children reluctant to take deep breaths due to abdominal pain. Monitoring and encouraging deep breathing can help prevent pulmonary complications.

• Lack of incentive spirometer use: Refusal to use the incentive spirometer reduces lung expansion, promoting atelectasis and increasing risk for infection. Incentive spirometry is essential to prevent postoperative pulmonary complications.

Rationale for incorrect choices

• Postoperative ileus: Absent bowel sounds are expected in the immediate postoperative period and are not abnormal within the first several hours after abdominal surgery. The child’s abdominal tenderness and soft abdomen are consistent with normal post-surgical recovery. Ileus becomes a concern if bowel sounds remain absent beyond 24–48 hours or if the child develops vomiting or abdominal distention.

• Peritonitis: The child shows no signs of systemic infection, rebound tenderness, or rigid abdomen. The incision is dry and intact, and vital signs are stable with only mild temperature elevation. Peritonitis would present with diffuse abdominal pain, guarding, and often fever, none of which are present.

• Breath sounds: Breath sounds are clear throughout, indicating no active pneumonia at this time. While lung expansion is limited, auscultation does not show crackles, wheezing, or other abnormal findings. Breath sounds alone do not indicate risk; shallow breathing and incentive spirometer non-use are more predictive of pulmonary complications.

• Absent bowel sounds: In the immediate postoperative period, bowel sounds may be decreased or absent for several hours due to anesthesia and surgical manipulation. This finding should not be interpreted as abnormal at this stage.