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    HESI LPN EXIT TEST 11 PROCTORED EXAM

    A client is receiving a postoperative continuous bladder irrigation via a three-way indwelling catheter for a transurethral resection of the prostate (TURP). Twelve hours after the surgery, the practical nurse (PN) is monitoring the urine in the catheter's bedside drainage unit and observes that the drainage is a thick red fluid with clots. What action should the PN implement?

    Explanation & Rationale

    A. Checking for kinks in the drainage tubing is important, but the observed clots and thick red fluid suggest potential complications that require immediate attention and should be reported. B. Waiting for an hour to observe again could delay necessary interventions if there's an issue with bleeding or clot formation, so reporting immediately is more prudent. C. Reporting the finding to the charge nurse is crucial as it indicates potential complications such as bleeding or clot formation that need immediate intervention. D. Stopping the irrigation solution without proper assessment and guidance could lead to complications and isn't the initial action warranted in this situation. Reporting to a superior nurse allows for prompt evaluation and intervention.

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