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    Ati rn comprehensive predictor 2023 proctored exam

    A nurse is assessing a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate 4 hr ago. The nurse notes pink-tinged urine in the drainage bag. Which of the following actions should the nurse take?

    Explanation & Rationale

    A. Perform the Credés maneuver: The Credés maneuver involves applying manual pressure over the bladder to promote voiding. This technique is contraindicated in clients with continuous bladder irrigation post-TURP, as it can disrupt the surgical site and increase the risk of bleeding or trauma. B. Maintain the irrigation solution rate: Pink-tinged urine is an expected finding in the immediate postoperative period following TURP. Maintaining the prescribed irrigation rate helps prevent catheter obstruction from clots, ensures continuous drainage, and reduces the risk of bladder distention and further bleeding. C. Replace the indwelling urinary catheter: Catheter replacement is unnecessary when urine is draining and pink-tinged, indicating minor bleeding rather than obstruction or malfunction. Routine replacement could introduce infection and trauma. D. Warm the irrigation solution: Warming the solution is generally not required unless the client experiences discomfort from cold fluid. It does not address the normal postoperative pink-tinged urine and does not influence clot prevention.

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