A client is receiving 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
The correct answer is Choice B. Report the finding to the charge nurse. Choice A rationale: Checking for kinks in the drainage tubing is an important troubleshooting step if there is a sudden decrease or absence of urine output. However, in this case, the PN's concern is the presence of thick red fluid with clots in the urine drainage. This finding indicates potential bleeding, which requires immediate attention and reporting. Choice B rationale: Reporting the finding to the charge nurse is the correct action. The presence of thick red fluid with clots in the urine suggests significant bleeding after the transurethral resection of the prostate (TURP) surgery. It is crucial to inform the charge nurse or the healthcare provider promptly so that appropriate interventions can be initiated to address the bleeding. Choice C rationale: Stopping the irrigation solution immediately may not be within the PN's scope of practice unless explicitly instructed by the healthcare provider. Moreover, abruptly stopping the irrigation may lead to complications, and it is essential to involve the charge nurse or healthcare provider in making this decision. Choice D rationale: Observing the drainage again in one hour is not appropriate in this situation. The presence of thick red fluid with clots in the urine drainage is an urgent concern that requires immediate action, not a wait-and-see approach.