The nurse is caring for a client receiving continuous bladder ...

[beccaep]

The nurse is caring for a client receiving continuous bladder irrigation following transurethral prostatectomy. When emptying the urine collection bag, the nurse notes that 500 mL of irrigant has infused with only 100 mL of drainage returned.
 
  Which is the priority action by the nurse?
 
  1. Irrigating the outflow port using an irrigation syringe to determine patency
  2. Notifying the health care provider immediately
  3. Irrigating the irrigation port to determine patency
  4. Continuing to monitor output

Question 2

When is it appropriate for the nurse to prepare a new ostomy pouch for a client?
 
  1. After removing the old pouch in all instances
  2. Before removing the old pouch in all instances
  3. Before removing the old pouch whenever possible
  4. After removing the old pouch whenever possible

[xiaomengxian]

Answer to Question 1

Correct Answer: 1

The outflow port that drains urine and irrigation fluid from the bladder should be irrigated gently to assure patency. If the port is blocked, the nurse should not apply excessive pressure but should notify the health care provider. The fluid is continuing to flow into the bladder, so there is no indication the irrigation port is blocked, making irrigation of this port unnecessary. Continuing to monitor output, without resolving the issue, could result in trauma to the client's bladder.

Answer to Question 2

Correct Answer: 3

Whenever possible, the new pouch should be prepared before removing the old pouch, because it reduces the risk of urine leakage onto the tissues, causing skin breakdown.

[beccaep]

Excellent

[kilada]

TYSM