A nurse is reinforcing teaching with an older adult client who has osteoporosis.
Which of the following recommendations should the nurse include?

Choice A rationale

Offering oral fluids increases the overall fluid load, which is generally helpful for increasing urinary output and flushing the urinary tract; however, the client is currently experiencing zero urinary output with continuous bladder irrigation (CBI). Before adding more fluid, the immediate priority is to ensure the outflow tract is clear; otherwise, the fluid will back up into the bladder, causing distention and pain.

Choice B rationale

Notifying the provider is a necessary step if the immediate measures to restore patency fail. A period of anuria post-TURP with CBI suggests a possible clot obstruction that could lead to severe bladder distention, pain, and potential bladder rupture. However, the nurse must first independently assess and attempt to correct the most common cause (occlusion) before escalation.

Choice C rationale

Administering an analgesic may temporarily alleviate pain associated with bladder spasms or distention caused by an occluded catheter. However, addressing the underlying mechanical problem (lack of output/obstruction) is the primary concern, as pain is a symptom of the blockage, not the cause. Restoring patency prevents complications and is the immediate priority.

Choice D rationale

The absence of urinary output with continuous bladder irrigation (CBI) strongly suggests the 3-way catheter is occluded, most likely by a blood clot or tissue fragments following the TURP. The first action is to determine patency by checking for kinks and attempting to gently manually irrigate the catheter using an aseptic technique and 30-50 mL of sterile normal saline solution per protocol to dislodge the obstruction.

Choice A rationale

Encouraging and assisting with turning every 2 hours is a standard intervention for any client with restricted mobility, including those on bedrest due to DVT. This measure helps prevent skin breakdown and pressure ulcers by relieving pressure over bony prominences and promoting circulation to compressed tissues.

Choice B rationale

Positioning the legs dependently (hanging down) would increase venous pressure and worsen venous pooling and edema distal to the DVT site due to the effects of gravity, which could potentially increase pain and swelling. The affected leg should be elevated above the level of the heart to promote venous return and reduce edema and pressure.

Choice C rationale

Ibuprofen, a non-steroidal anti-inflammatory drug (NSAID), inhibits platelet aggregation and may increase the risk of bleeding when used concurrently with therapeutic anticoagulants like heparin or warfarin, which are standard DVT treatments. Acetaminophen (Tylenol) is generally preferred for pain management due to its lower bleeding risk.

Choice D rationale

Heparin (unfractionated or low molecular weight) is a common treatment for DVT. A severe complication of heparin therapy is Heparin-Induced Thrombocytopenia (HIT), an immune reaction leading to a significant drop in platelet count (normal range 150,000–450,000/mm) and paradoxical thrombosis. Therefore, monitoring platelet levels is crucial.

Choice E rationale

Applying ice (cold) to the extremity is a vasoconstrictor that can impair circulation and may reduce pain but is not the primary intervention for an acute DVT; it could theoretically worsen flow. Moist heat application is often preferred to promote vasodilation, which may reduce muscle spasms and provide comfort.

Choice F rationale

Compression stockings (graduated compression) help to reduce edema and promote venous return from the lower extremities, thereby reducing the symptoms of Post-Thrombotic Syndrome (PTS). The nurse must evaluate the fit to ensure the stockings are not too tight (risk for impaired arterial circulation) or too loose (ineffective compression).