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. Does not include humor.
Humor can be an appropriate part of the nurse-patient relationship when used sensitively to ease tension or build rapport.
B. Continues after discharge.
The therapeutic relationship typically ends upon discharge, respecting professional boundaries.
C. Focuses on the assessed patient health problems.
The nurse-patient relationship centers on addressing the patient’s identified health issues and providing support, making this option accurate.
D. Focuses on the nurse's ability to build rapport.
While rapport is important, the primary goal is to address the patient’s health needs, not just rapport-building alone.
Correct Answer is B
Explanation
A. Avoiding frequent eye pressure measurements is not advisable; monitoring eye pressure is crucial in managing glaucoma.
B. Maintaining the prescribed eye drop regimen is the most important instruction because consistent use of these medications is critical to managing intraocular pressure and preventing vision loss associated with glaucoma.
C. While wearing prescription glasses can assist with vision, it does not address the underlying condition of glaucoma.
D. Eating a diet high in carotene is beneficial for overall eye health but does not directly impact the management of glaucoma. Regular use of prescribed eye drops is essential to prevent further damage to the optic nerve and potential blindness.