A practical nurse is caring for a client receiving continuous bladder irrigation following a transurethral resection of the prostate. The client suddenly reports severe lower abdominal cramping, and the nurse observes that there is no fluid draining into the urinary collection bag. In what order should the practical nurse perform the following actions? (Arrange from first to last)
- 1Inspect the urinary drainage tubing for kinks or dependent loops.
- 2Clamp the continuous bladder irrigation infusion.
- 3Palpate the client's suprapubic region for distention.
- 4Notify the registered nurse of the assessment findings.
Answer
The correct sequence is: Inspect the tubing, clamp the infusion, palpate the bladder, and then notify the registered nurse.
When a client on continuous bladder irrigation experiences sudden pain and a lack of output, an obstruction is highly likely. The nurse must first perform the quickest non-invasive check by inspecting the drainage tubing for kinks. If the tubing is clear, the blockage is internal (often a blood clot). The immediate safety priority is to clamp the flow of irrigation to prevent bladder rupture from continuous fluid input. After securing the client's safety, the nurse assesses the physical impact by palpating the bladder to gauge distention. Finally, the nurse reports these comprehensive findings to the registered nurse, who can initiate advanced interventions like manual irrigation to clear the clot.
Step-by-Step Solution
Key Concept
Prioritization in Acute Obstruction