On the first postoperative day, a patient with a TURP complains of abdominal pain. The nurse finds that the bladder is greatly distended. What should the nurse do next?
a. Inform the charge nurse.
b. Irrigate the indwelling catheter with 20 to 30 mL of normal saline.
c. Increase the continuous bladder irrigation flow rate.
d. Turn the patient to the right side.
B
The patient most likely has a clot that is occluding the catheter and causing pressure on the blad-der. Additional irrigation will dislodge the clot that is occluding the catheter. Increasing conti-nuous bladder irrigation flow rate would add fluid to the bladder and increase pain. It is within the primary care nurse's role to perform the intervention without notifying the charge nurse. Turning the patient to the right side does not offer benefit.
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