The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which is the best initial nursing action?

Choice A reason: A complete blood count (CBC) is the most relevant laboratory value to review for a client with iron deficiency anemia who reports increased fatigue. The CBC will provide important information about the levels of red blood cells, hemoglobin, and hematocrit, which are directly affected by iron deficiency. Monitoring these values will help determine if the client’s anemia is worsening or if the iron supplements are not effectively improving the blood count.

Choice B reason: The platelet count is part of a CBC but is not directly related to the symptoms of fatigue in iron deficiency anemia. While platelet levels are important for assessing clotting function, they do not provide the necessary information about red blood cell levels or hemoglobin concentration that are central to diagnosing and managing anemia.

Choice C reason: Serum electrolytes are important to monitor for overall health and hydration status, but they are not specifically related to the client’s anemia or the symptom of fatigue. Electrolyte imbalances typically do not cause fatigue related to anemia, so this is not the primary laboratory value to review in this context.

Choice D reason: Liver enzymes are important for assessing liver function and potential liver damage, but they are not directly related to iron deficiency anemia or the symptom of fatigue. While it is important to monitor liver health, especially if the client is on medications that affect the liver, the complete blood count is more relevant to the symptoms described.

Choice A reason: Activity intolerance related to ischemia is a common concern for clients with AMI, but it is not the primary nursing problem when the client is receiving thrombolytic therapy. The focus should be on monitoring for complications related to the therapy itself.

Choice B reason: Risk for injury related to effects of thrombolytics is the priority nursing problem for a client receiving thrombolytic therapy. Thrombolytics can cause serious bleeding complications, including internal bleeding, hemorrhage at vascular access sites, gastrointestinal bleeding, or intracranial bleeding. The nurse must closely monitor the client for signs and symptoms of bleeding, such as sudden onset or worsening of headache, changes in level of consciousness, hematuria, melena, ecchymosis, or hematoma formation.

Choice C reason: Ineffective breathing pattern related to adverse drug effects can occur following thrombolytic therapy, but it is not the primary concern. The risk of bleeding complications takes precedence as the priority nursing problem for this client.

Choice D reason: Deficient knowledge related to a new medication regimen is important for client understanding and adherence, but it is not the priority nursing problem in the immediate post-thrombolytic therapy period. Ensuring the client's safety by monitoring for bleeding complications is the primary focus.