A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate. A triple lumen catheter for continuous bladder irrigation with normal saline is infusing, and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?
Discontinue infusing solution.
Irrigate the catheter manually.
Monitor catheter drainage.
Decrease the flow rate.
The Correct Answer is B
A. Discontinuing the infusion may lead to increased clotting and potential obstruction of the catheter. Continuous bladder irrigation is essential to keep the bladder clear of clots and debris following surgery.
B. Manually irrigating the catheter can help clear any clots that may be obstructing the catheter, ensuring adequate drainage and preventing complications such as bladder distention or retention. This is the most immediate and appropriate action to take in response to the presence of clots.
C. Monitoring catheter drainage is important; however, it does not address the potential issue of clots obstructing the flow of urine, which is the priority concern in this scenario.
D. Decreasing the flow rate may not be beneficial and could lead to inadequate irrigation of the bladder, which could exacerbate clot formation and urinary retention.
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Correct Answer is C
Explanation
A. A nursing care plan in the medical record before assessing the patient so that the nurse can identify priorities. The nurse should assess the patient first to determine their needs and priorities rather than create a care plan without assessment.
B. At least three times during the shift: at the beginning, in the middle, at the end, and as needed. Regular documentation is good practice, but the initial assessment must be documented at the beginning of the shift to establish a baseline.
C. An initial assessment of the patient and a plan based on the needs of the patient as assessed at the beginning of the shift. Documenting an initial assessment is crucial for identifying immediate needs and planning care, especially after surgery.
D. At the end of the shift so that the nurse can give full attention to the patient's needs during the shift. Waiting until the end of the shift risks missing critical changes and does not provide a clear baseline assessment.
Correct Answer is B
Explanation
A. restatement. Restatement involves repeating the patient’s words exactly, while here, the nurse is rephrasing the sentiment.
B. reflection. Reflection focuses on the patient’s feelings or experiences by paraphrasing their statement, helping the patient explore their feelings, which the nurse is doing here.
C. open-ended question. An open-ended question would be broad, allowing the patient to provide more information. This response is a restatement, not a question.
D. offering self. Offering self involves expressing a willingness to stay or support the patient, which is not demonstrated here.