Question

159. A nurse is caring for a client who had a transurethral

resection of the prostate and has continuous bladder irrigation.
Which of the following actions should the nurse take first?
a. I can see th

Answer 1

The nurse should assess the patency of the urinary catheter and drainage system.

Step-by-step explanation:

In caring for a client who underwent transurethral resection of the prostate (TURP) with continuous bladder irrigation (CBI), the priority action for the nurse is to assess the patency of the urinary catheter and drainage system. Continuous bladder irrigation is commonly used post-TURP to prevent blood clot formation and ensure adequate urine drainage. If the catheter becomes blocked, it can lead to urinary retention, causing discomfort and potentially compromising the surgical outcome.

Firstly, the nurse should visually inspect the tubing and drainage bag for any kinks, twists, or clots. If the system appears obstructed, the nurse should gently irrigate the catheter with sterile saline to clear any clots. Additionally, assessing the client's urine output and monitoring for signs of bladder distention or discomfort are crucial aspects of ensuring the effectiveness of CBI.

Prompt intervention to address catheter-related issues is essential to prevent complications such as infection or urinary retention. Regular assessment and maintenance of the urinary drainage system are fundamental in providing safe and effective postoperative care for clients who have undergone TURP with continuous bladder irrigation.

Answer 2

The nurse should prioritize assessing the client's vital signs and urinary output post TURP to promptly identify and address potential complications such as bleeding or fluid overload. This ensures early intervention and promotes the client's overall stability during the critical postoperative period.

Step-by-step explanation:

In the immediate postoperative care of a client who has undergone a transurethral resection of the prostate (TURP) with continuous bladder irrigation, the nurse's first and foremost action should be to assess the client's vital signs and urinary output. This is imperative for early identification of potential complications that may arise following the surgical procedure. Monitoring vital signs, including heart rate, blood pressure, and respiratory rate, is crucial to detect any signs of hemodynamic instability, such as excessive bleeding or cardiovascular compromise. Timely recognition of these issues allows for prompt intervention and can prevent further complications.

Simultaneously, assessing urinary output is essential in evaluating the effectiveness of continuous bladder irrigation. This helps the nurse monitor for signs of urinary retention or inadequate irrigation, which could lead to clot formation and hinder the client's recovery. By prioritizing these assessments, the nurse ensures the overall stability and well-being of the client during the critical postoperative period.

In summary, the initial focus on vital signs and urinary output establishes a baseline for the ongoing management of the client, guiding subsequent interventions and promoting a proactive approach to address potential complications promptly.