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: Ensuring the IV solution is infusing at the prescribed rate is important, but it is not the first action the nurse should take. The symptoms the client is exhibiting—low blood pressure, tachycardia, restlessness, and irritability—are indicative of potential hypovolemic shock, likely due to bleeding. Immediate assessment for bleeding is more critical.

Choice B reason: Notifying the healthcare provider of the findings is essential, but it should be done after assessing the client for signs of bleeding. The nurse needs to quickly identify the source of the client’s symptoms before contacting the healthcare provider to provide a complete and accurate report of the situation.

Choice C reason: Checking under the back for evidence of bleeding is the correct first action. The client's symptoms suggest they might be experiencing hypovolemic shock due to postoperative bleeding. Identifying whether there is visible bleeding can help determine the next steps in managing the client's condition and providing appropriate interventions.

Choice D reason: Listening to lung sounds is important in a comprehensive assessment but is not the priority in this scenario. The client's symptoms strongly indicate a potential bleeding issue, so checking for evidence of bleeding should come first to promptly address the most life-threatening concern.

Choice A reason: Notifying the surgical team to cancel the surgery is premature without confirming the pregnancy status. While it is critical to consider the possibility of pregnancy before surgery, the decision to cancel should be based on confirmed information rather than a possibility.

Choice B reason: Performing a bedside pregnancy test is the most appropriate immediate intervention. This test can provide rapid confirmation of pregnancy status. If the client is pregnant, the surgical team can then evaluate the risks and benefits of proceeding with or postponing the surgery. Immediate confirmation helps guide clinical decision-making and ensures the safety of both the client and the potential fetus.

Choice C reason: Continuing with surgery as scheduled without confirming the pregnancy status is not appropriate. Anesthesia and surgical procedures can pose risks to a pregnant client and the fetus. It is essential to verify the pregnancy status to make an informed decision about the safety and necessity of the surgery.

Choice D reason: Calculating gestation from the last menstrual cycle can provide an estimate of the pregnancy duration, but it does not confirm pregnancy. A bedside pregnancy test should be performed first to confirm whether the client is pregnant before considering gestational age. This information can then be used to further assess the situation and plan appropriate care.