A practical nurse is monitoring a client who is 6\text{ hours} postoperative following a t… — NCLEX-PN

A practical nurse is monitoring a client who is $6\text{ hours}$ postoperative following a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigation (CBI). Which of the following assessment findings indicate a developing complication that requires immediate escalation to the registered nurse? Select all that apply.

Urinary drainage in the collection bag that rapidly transitions from light pink to bright red with large clotsAnswer
B
A morning serum hemoglobin level of $14.2\text{ g/dL}$ and hematocrit of $42\%$
A heart rate of $118\text{ beats/minute}$ and a blood pressure of $92/54\text{ mm Hg}$ Answer
D
An oral temperature of $99.1^\circ\text{F}$ ( $37.3^\circ\text{C}$ ) during the most recent vital signs check
The client reports sudden, severe lower abdominal cramping and an intense urge to voidAnswer
F
The client resting comfortably in a supine position with the head of the bed elevated $30$ degrees

Answer

The correct findings requiring immediate escalation are the transition to bright red drainage with clots, tachycardia with hypotension, and severe lower abdominal cramping.

The correct findings directly point to life-threatening complications of a transurethral resection of the prostate (TURP). Bright red drainage with large clots indicates active arterial bleeding rather than expected venous oozing. A heart rate of

118\text{ beats/minute}

with a blood pressure of

92/54\text{ mm Hg}

are decompensatory signs of hypovolemic shock resulting from blood loss. Sudden, severe lower abdominal cramping with an urge to void indicates severe bladder spasms or a blocked catheter, which can cause bladder trauma and worsen bleeding. All three require immediate escalation for registered nurse or provider intervention.

Step-by-Step Solution

Analyze the client's postoperative status.

The client is

6\text{ hours}

post-TURP with continuous bladder irrigation, making them highly vulnerable to hemorrhage and catheter obstruction.

Identifying the specific surgical procedure and time frame highlights the expected risks versus normal recovery signs.

Evaluate each finding to differentiate expected post-procedure outcomes from acute complications.

Bright red drainage with clots, tachycardia with hypotension, and severe cramping represent active bleeding, shock, and obstruction.

The practical nurse must recognize signs that deviate from normal recovery and fall outside their independent scope of practice to resolve.

Identify findings that are benign or expected.

Normal hemoglobin and hematocrit, mild temperature elevation, and a

30

-degree bed elevation are all safe, expected findings.

Escalating normal findings demonstrates a lack of clinical judgment regarding physiological adaptation to surgery.

Key Concept

Recognizing postoperative complications following TURP, specifically hemorrhage, shock, and catheter obstruction.

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