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. "Take the vital signs on all the patients in the lounge and tell me whether there are problems." This instruction is vague and lacks specific information about what "problems" to look for, which may lead to inconsistent reporting.
B. "Do the morning care first on the patients in 205 and 206 who can't get out of bed." This instruction is clear, but it does not specify important details like the specific type of care expected or additional needs.
C. "Give the patient in 204A a shower after breakfast, and call me to check her feet before you get her dressed." This instruction is specific, clear, and provides a follow-up action (check her feet) which is necessary. It allows the nursing assistant to understand exactly what to do and when.
D. "You take care of all the patients in 205 and 206. Let me know how you're doing and whether you need any help." This instruction lacks specificity and does not outline clear tasks or expectations, which may lead to confusion.
Correct Answer is D
Explanation
A. Visible swelling of the neck may indicate other conditions, such as thyroid issues, but it is not a characteristic finding of Cushing's syndrome.
B. Warm, soft, moist, salmon-colored skin is more indicative of hyperthyroidism rather than Cushing's syndrome, which typically presents with thin, fragile skin.
C. A husky voice and hoarseness can occur due to various reasons, but they are not classic symptoms of Cushing's syndrome.
D. Central type obesity, characterized by a rounded face and thin extremities, is a hallmark feature of Cushing's syndrome, caused by excessive cortisol levels leading to fat redistribution.