Question

The nurse provides care for a client who had a transurethral resection of the prostate (TURP). The client has a three-way urinary catheter connected by gravity with continuous bladder irrigation (CBI) of normal saline. Which observations require the nurse to intervene? (Select all that apply.)

1. Temperature of 101.4°F (38.3°C).
2. Urinary output of 100 mL in 4 hours.
3. Fluid leakage around the catheter tubing.
4. Blood pressure of 112/76 mm Hg.
5. 230 mL of sanguinous fluid in the catheter bag.
6. Client reports pressure in the pelvis.

Answer 1

Observations that require intervention in a client with a 3-way urinary catheter and continuous bladder irrigation after TURP include elevated temperature, fluid leakage around the catheter tubing, and low urinary output.

Step-by-step explanation:

Observations that require the nurse to intervene when caring for a client with a 3-way urinary catheter connected to continuous bladder irrigation (CBI) of normal saline after transurethral resection of the prostate (TURP) include the following:

1. Temperature of 101.4°F (38.3°C): An elevated temperature may indicate infection and should be assessed and treated if necessary.
2. Fluid leakage around the catheter tubing: This may indicate a disconnection or malfunction, which requires immediate intervention to prevent complications and ensure proper irrigation.
3. Urinary output of 100 mL in 4 hours: This low urinary output may indicate inadequate bladder irrigation or obstruction, requiring further assessment and intervention.
4. Blood pressure of 112/76 mm Hg: A blood pressure within a normal range does not require immediate intervention.
5. 230 mL of sanguinous fluid in the catheter bag: This is an expected finding after TURP and is not a cause for concern.
6. Client reports pressure in the pelvis: This is a common complaint after TURP due to bladder spasms and may be managed with medication.