Difficulty: Medium
Average Score: 86%
Simulated
Passage / Scenario
A nurse is assessing a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate 4 hours ago. The nurse notes pink tinged urine and the drainage bag.Which of the following actions should the nurse take?
Correct answer
A
Rationale
The correct answer is A: Maintain the irrigation solution rate. This is the appropriate action because maintaining the irrigation solution rate ensures continuous flushing of the catheter to prevent blockages and maintain patency. Increasing the rate could lead to complications like fluid overload. Clamping the catheter and reassessing can cause catheter obstruction. Notifying the provider immediately may not be necessary unless there are specific complications or concerns.