NCLEX-PN® ExaminationReduction of Risk PotentialHard
An LPN is monitoring a client who is receiving a continuous bladder irrigation (CBI) after a transurethral resection of the prostate (TURP). The LPN observes dark red urine with several blood clots in the drainage bag. What is the most appropriate initial nursing action?
- ADocument the finding and continue to monitor.
- BDiscontinue the CBI and clamp the catheter.
- CIncrease the flow rate of the irrigating solution.
- DNotify the registered nurse (RN) or healthcare provider immediately.
Show answer & explanationAnswer & explanation
Correct answer: C. Increase the flow rate of the irrigating solution.
Dark red urine with clots indicates active bleeding and a risk of catheter obstruction. Increasing the flow rate of the irrigating solution helps to flush out clots and prevent obstruction, which is a priority to maintain catheter patency and prevent bladder distention. The RN/provider should be notified after this initial intervention.
Why the other options are wrong
- A. Documenting is necessary but not the immediate action when an acute change is observed; active intervention is needed.
- B. Discontinuing the CBI and clamping the catheter would lead to bladder distention and increased pressure, worsening the situation.
- D. While notifying the RN/provider is important, it should be done after the immediate action to prevent catheter obstruction.
CBI Management Post-TURP
Nursing care for continuous bladder irrigation after transurethral resection of the prostate, focusing on maintaining patency, assessing drainage, and managing complications.
- Purpose: prevent clot formation and obstruction.
- Monitor drainage color and for clots.
- Adjust flow rate to keep drainage clear or pinkish.
Memory trick: TURP CBI: 'T'hink 'U'rine 'R'ed, 'P'ush 'F'luid.