Question

The nurses observes that a postoperative client with a continuous bladder irrigation has a large blood clot in the urinary drainage tubing. What actions should the nurse perform first?

Answer 1

The nurse's first action should be to assess the catheter's patency and attempt to gently flush the catheter if the protocol allows. If unsuccessful, the physician should be notified promptly, and vital signs should be monitored.

Step-by-step explanation:

If a postoperative client with continuous bladder irrigation has a large blood clot in the urinary drainage tubing, the nurse's first action should be to assess the situation quickly to maintain the patency of the catheter. This may involve gently flushing the catheter, as per the physician's orders or as the protocol allows, to remove the clot.

If the irrigation fluid and urine output are not flowing freely or if the clot is unable to be cleared, the nurse should report this immediately to the physician. Additionally, the nurse should monitor the patient's vital signs, check for signs of bladder distention, and watch for any increase in pain or bleeding, as these could indicate a worsening of the condition. Documentation of the event and the interventions performed is also crucial.