Question of the Week – June 28, 2023
The nurse is assisting in caring for a client who has returned from the postanesthesia care unit after prostatectomy. The client has a three-way Foley catheter with an infusion of continuous bladder irrigation (CBI). Which color description of the urinary drainage should lead the nurse to determine that the flow rate is adequate?
Rationale:
Answer: 3
Rationale: The infusion of bladder irrigant is not at a preset rate; rather, it is increased or decreased to maintain urine that is a clear, pale yellow color or that has just a slight pink tinge. The infusion rate should be increased if the drainage is cherry colored or if clots are seen. Alternatively, the rate can be slowed down slightly if the returns are as clear as water.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Adult Health: Renal and Urinary
Health Problem: Adult Health: Renal and Urinary: Obstructive Problems
Practice Question Sourced From: Evolve Resources for Saunders Q & A Review for the NCLEX-PN® Examination, 5th Edition
