Which observation by the nurse best indicates that a continuous bladder irrigation for a patient following genitourinary surgery is effective?
a. Output that is smaller than the amount instilled
b. Blood clots or sediment in the drainage bag
c. Bright red urine turns pink in the tubing
d. Bladder distention with tenderness
ANS: C
If urine is bright red or has clots, increase irrigation rate until drainage appears pink, indicating successful irrigation. Expect more output than fluid instilled because of urine production. If output is smaller than the amount instilled, suspect that the tube may be clogged. The presence of blood clots indicates the patient is still bleeding, while sediment could mean an infection or bleeding. The bladder should not be distended or tender; the irrigant may not be flowing freely if these occur, or the tube may be kinked or blocked.
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