A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain. Which of the following actions should the nurse take first?
A.
Administer PRN pain medication.
B.
Check the client’s urine output.
C.
Reposition the dent in bed
D.
Monitor the clients fluid intake
The Correct Answer and Explanation is:
The correct answer is B. Check the client’s urine output.
Explanation:
Following a transurethral resection of the prostate (TURP), continuous bladder irrigation (CBI) is often used to prevent blood clots from obstructing the urinary catheter. This procedure involves the continuous infusion of a saline solution into the bladder to keep it clear of clots, which is crucial for ensuring proper urinary drainage.
When a client reports sharp lower abdominal pain after a TURP with CBI, the first priority is to assess whether the bladder is being properly drained. Pain in this context may indicate bladder distention, which is a common complication if the catheter becomes blocked by blood clots or debris. Bladder distention can cause sharp pain due to increased pressure and can lead to other complications such as bladder rupture or decreased kidney function. Therefore, checking the client’s urine output is the first action the nurse should take to determine if there is a blockage.
If the nurse finds that the urine output is significantly reduced or absent, this suggests that the catheter might be obstructed. The nurse should troubleshoot the irrigation system by checking for kinks in the tubing and manually irrigating the catheter to remove any blockages. If this resolves the issue, urine flow will be restored, and the client’s pain should decrease as the bladder is no longer distended.
Why the Other Options Are Incorrect:
- A. Administer PRN pain medication: While pain relief is important, addressing the cause of the pain (which could be a blockage) takes precedence. Giving pain medication without assessing the cause could delay proper intervention.
- C. Reposition the client in bed: Although repositioning can sometimes help with comfort, it will not address the underlying cause of sharp abdominal pain, which could be due to a blocked catheter.
- D. Monitor the client’s fluid intake: Fluid monitoring is important in general care but is not the priority when a client is experiencing acute pain potentially related to bladder distention.
In summary, checking the client’s urine output is the priority to rule out a catheter blockage and prevent further complications.