Which observation by the nurse best indicates that bladder irrigation for urinary retention has been effective?
a. Recording an output that is larger than the amount instilled
b. Presence of blood clots or sediment in the drainage bag
c. Reduction in discomfort from bladder distention
d. Visualizing clear urinary catheter tubing
ANS: A
Recording an output that is greater than what was irrigated into the bladder shows progress that the bladder is draining urine. The other observations do not objectively measure the increase in urine output.
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