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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?

A.

Discontinue infusing solution.

B.

Irrigate the catheter manually.

C.

Monitor catheter drainage.

D.

Decrease the flow rate.

Answer and Explanation

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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View Related questions

Correct Answer is B

Explanation

A. Latent hepatitis C is not an absolute contraindication for peritoneal dialysis, and patients with this condition can often undergo dialysis with appropriate precautions.

B. Crohn's disease with a history of colectomy poses a risk for peritoneal dialysis due to potential intra-abdominal adhesions and infection, which can complicate the procedure and increase the risk of peritonitis.

C. A history of nephrotic syndrome does not contraindicate peritoneal dialysis; patients with nephrotic syndrome may still be candidates depending on their overall kidney function and health status.

D. Type 2 diabetes mellitus is a common condition among patients needing dialysis and does not preclude the use of peritoneal dialysis, as long as blood sugar levels are managed effectively.

Correct Answer is D

Explanation

A. While bowel sounds can indicate gastrointestinal activity, they do not directly correlate with pain management or the underlying cause of abdominal discomfort in chronic pancreatitis.

B. The level and amount of physical activity may impact overall well-being but are less directly related to the management of abdominal pain from pancreatitis.

C. The color and consistency of feces can provide some information regarding pancreatic function and fat absorption but is not the most immediate factor affecting pain management.

D. Understanding the client’s eating patterns, including food triggers and timing, is crucial because certain foods can exacerbate abdominal pain in chronic pancreatitis. Dietary adjustments can significantly help manage symptoms and improve quality of life.

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