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    HESI RN Medical Surgical Proctored Exam

    A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate (TURP). A triple-lumen catheter for continuous bladder irrigation with 0.9% sodium chloride 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?

    Explanation & Rationale

    A. Discontinuing the infusion of the solution may compromise the effectiveness of continuous bladder irrigation, which is typically indicated after TURP to prevent clot retention and ensure urinary drainage.B. Manual irrigation of the catheter may disrupt the established irrigation system and lead to further complications. It is not the initial action to take in this situation.C. Monitoring catheter drainage allows the nurse to assess the effectiveness of bladder irrigation and the presence of clot formation. Continued observation is necessary to ensure adequate drainage and identify any signs of complications.D. Decreasing the flow rate may not address the underlying issue of clot retention and may not be appropriate without further assessment of the client's condition.

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