The first time that a client voids after cystoscopy, the nurse observes pink-tinged urine. What is the appropriate nursing response?

Choice A rationale Cystoscopy involves the insertion of a scope through the urethra into the bladder, which can cause minor trauma to the mucosal lining. It is a normal and expected finding for the patient to have pink-tinged urine or slight hematuria during the first few voidings after the procedure. The nurse should document this as an expected outcome of the diagnostic intervention. Normal urine is pale yellow; however, mild irritation from the scope accounts for this temporary change. Choice B rationale Restricting fluids is incorrect; in fact, the nurse should encourage increased fluid intake after a cystoscopy. Increasing oral fluids helps to flush the bladder, dilute any blood present, and reduce the risk of urinary tract infection following the instrumentation. Promoting high urine flow also helps clear any small clots and minimizes the burning sensation or dysuria that patients often experience during their first post-procedure void. Fluids should be encouraged, not restricted. Choice C rationale Notifying the health care provider for pink-tinged urine after a cystoscopy is unnecessary because it is an expected postoperative finding. The nurse should only notify the provider if the urine becomes bright red, contains large clots, or if the patient is unable to void at all. Since this is the first voiding, minor discoloration is anticipated. Efficient nursing involves distinguishing between normal procedural side effects and actual complications like significant hemorrhage or urinary retention. Choice D rationale Contacting the Rapid Response Team is an extreme and inappropriate reaction to an expected clinical finding. Rapid Response is reserved for patients showing signs of acute clinical deterioration, such as respiratory distress, hypotension, or sudden neurological changes. Pink-tinged urine after a bladder procedure does not constitute a medical emergency. The nurse must use clinical judgment to provide reassurance and monitor the patient rather than escalating to emergency services for a routine and stable observation.