At 1 hour after transurethral prostate surgery, a client receiving continuous bladder irrigation has suprapubic pain and bladder spasms. The irrigant infused is 500 mL, but drainage is 75 mL. Which action should the nurse take first?
1Increase the irrigation rate and document the drainage as an expected finding
2Subtract the irrigant volume and record a negative urine output for the hour
3Inspect the catheter and tubing for kinks or clots that are blocking outflow✓ Correct answer
4Clamp the irrigation and remove the catheter before notifying the urology team
Explanation
Drainage far below the 500 mL infused, with suprapubic pain and spasms, suggests obstructed outflow and bladder distention. First inspect the system for kinks or clots and restore prescribed drainage. Increasing inflow can worsen distention when outflow remains blocked.
Quick answer Check the catheter and tubing for a mechanical obstruction before adding more irrigant.
Why this is correct Continuous bladder irrigation must flow into and out of the bladder. A large input-output gap with pain and spasms signals that fluid may be trapped behind a kink or clot, so restoring outflow is the immediate safety goal.
Easy analogy or mental picture The irrigation system works like water entering and leaving a sink. If water enters but little exits, check the drain before opening the faucet wider. The analogy does not authorize manual irrigation unless it is prescribed and within policy.
Memory hook CBI pain plus low return: check the outflow before increasing the inflow.
NCLEX decision rule For continuous bladder irrigation, compare irrigant input with total drainage; pain, spasms, and unexpectedly low return require immediate assessment for obstruction.
Why the other choices are wrong Increasing inflow can enlarge a distended bladder. Recording a negative output does not correct the obstruction, and catheter removal can disrupt postoperative hemostasis and requires an appropriate prescription.
References
[1]
NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing
[2]
Bladder Irrigation: Management of HaematuriaNSW Agency for Clinical Innovation Urology Network
Clinical Practice GuideFor Metformin and iodinated contrast, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.
CautionDo not choose an action from one isolated cue when the full scenario changes priority or safety.
Iodinated Contrast — A contrast agent used for some imaging studies that can affect kidney safety.
Metformin — An oral medication used to treat type 2 diabetes.
Kidney Function — Assessment of renal ability to filter and excrete waste or medications.