During a clinic visit, a mother tells the practical nurse (PN) that she keeps her 2-year-old child in a playpen so he will not get dirty. Which rationale should the PN use in responding to this parent?

The correct answer is Choice B. Report the finding to the charge nurse. Choice A rationale:

Checking for kinks in the drainage tubing is an important troubleshooting step if there is a sudden decrease or absence of urine output. However, in this case, the PN's concern is the presence of thick red fluid with clots in the urine drainage. This finding indicates potential bleeding, which requires immediate attention and reporting.

Choice B rationale:

Reporting the finding to the charge nurse is the correct action. The presence of thick red fluid with clots in the urine suggests significant bleeding after the transurethral resection of the prostate (TURP) surgery. It is crucial to inform the charge nurse or the healthcare provider promptly so that appropriate interventions can be initiated to address the bleeding.

Choice C rationale:

Stopping the irrigation solution immediately may not be within the PN's scope of practice unless explicitly instructed by the healthcare provider. Moreover, abruptly stopping the irrigation may lead to complications, and it is essential to involve the charge nurse or healthcare provider in making this decision.

Choice D rationale:

Observing the drainage again in one hour is not appropriate in this situation. The presence of thick red fluid with clots in the urine drainage is an urgent concern that requires immediate action, not a wait-and-see approach.

Choice A rationale:

Pantoprazole is a proton pump inhibitor used to treat GERD by reducing stomach acid production. If the client reports not experiencing heartburn after eating lunch, it indicates that the medication is effectively reducing stomach acid and alleviating GERD symptoms.

Choice B rationale:

The ability to swallow food without difficulty is not directly related to the desired effect of pantoprazole. It may be an important aspect of the client's overall condition, but it does not specifically indicate the efficacy of the medication in treating GERD.

Choice C rationale:

Having no difficulty straining for a bowel movement is unrelated to the desired effect of pantoprazole in treating GERD. Pantoprazole does not directly influence bowel movements.

Choice D rationale:

Having a great appetite and feeling hungry are not relevant indicators of the effectiveness of pantoprazole in treating GERD. These statements are more related to the client's appetite and overall well-being rather than the response to the medication.