A client has returned from a transurethral resection of the prostate with a continuous bladder irrigation. Which action by the nurse is a priority if bright red urinary drainage and clots are noted 5 hours after the surgery?
a. Review the hemoglobin and hematocrit as ordered.
b. Take vital signs and notify the surgeon immediately.
c. Release the traction on the three-way catheter.
d. Remind the client not to pull on the catheter.
ANS: B
Bright red urinary drainage with clots may indicate arterial bleeding. Vital signs should be taken and the surgeon notified. The traction on the three-way catheter should not be released since it places pressure at the surgical site to avoid bleeding. The nurse's review of hemoglobin and hematocrit and reminding the client not to pull on the catheter are good choices, but not the priority at this time.
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