Question

When assessing a client two hours after a transurethral prostatectomy, the nurse notes that the catheter drainage is dark red in color and contains a few clots. Which actions should the nurse take at this time? A. Document the finding and continue to observe the drainage B. Notify the physician immediately and increase the rate of IV fluids C. Place traction on the catheter and tape it to the client's upper thigh D. Request a CBC to determine the amount of blood loss

Short answer

Answer: Notify the physician immediately and increase the rate of IV fluids.

Step-by-step solution

Analyze the situation

To address this question, it is important to understand the context. A transurethral prostatectomy is a surgical procedure to remove part or the entire prostate gland. Dark red colored catheter drainage with clots may indicate a postoperative complication such as bleeding.

Assess each option

We will now analyze each option to determine the most appropriate nursing intervention in this situation. A. Document the finding and continue to observe the drainage: While documentation is important, this option does not provide any active intervention to address the potential bleeding issue. B. Notify the physician immediately and increase the rate of IV fluids: This option involves notifying the physician, which is a relevant step when suspecting postoperative complications. Increasing the rate of IV fluids can help maintain appropriate blood volume and pressure. C. Place traction on the catheter and tape it to the client's upper thigh: This option does not directly address the potential bleeding issue and focuses only on catheter placement. D. Request a CBC to determine the amount of blood loss: While a CBC might provide valuable information about the client's blood levels, it does not directly address the potential bleeding issue or provide an immediate intervention.

Choose the most appropriate option

Based on the analysis of each option, the most appropriate nursing intervention in this situation would be option B. Notify the physician immediately and increase the rate of IV fluids which addresses the potential bleeding issue and provides an active intervention to help maintain the client's blood volume and pressure.