Question

the nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a trans-urethral resection of the prostate (turp).what is the best initial nursing action?

Answer 1

The nurse should immediately notify the physician if increased blood clots are observed in the drainage of a patient post-TURP, assess vital signs, check for hemorrhage, and ensure proper rate and unobstructed flow of the bladder irrigation.

Step-by-step explanation:

The best initial nursing action when a nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a trans-urethral resection of the prostate (TURP) is to notify the physician immediately. This could indicate a complication such as bleeding within the bladder or that the irrigation is not effectively flushing out the bladder. Immediate assessment and intervention are critical to prevent further complications. Additionally, the nurse should assess the client's vital signs, monitor for signs of hemorrhage, and ensure that the bladder irrigation is running at the correct rate and without obstruction.

Answer 2

The best initial nursing action when observing an increased number of blood clots in the drainage tubing of a TURP patient is to promptly notify the physician and assess the patient's vital signs, the color and consistency of the irrigation output, and measure input and output for balance.

Step-by-step explanation:

Initial Nursing Action for Increased Blood Clots in Drainage Tubing:

The presence of an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a trans-urethral resection of the prostate (TURP) is a concern that requires immediate attention. The best initial nursing action would be to notify the physician promptly. This is critical as it may indicate postoperative bleeding, which could lead to complications such as clot retention or bladder tamponade.

Additionally, the nurse should assess the patient's vital signs, check the color and consistency of the irrigation output, and measure the input and output to ensure that there is no fluid imbalance or signs of hemorrhage. While waiting for the physician's assessment and orders, the nurse should also ensure that the irrigation is running at the correct flow rate to prevent clots from obstructing the catheter and maintain patency. Any changes in the patient's condition should be documented and closely monitored.