# A patient is post-op day 0 from a transurethral resection of the prostate (TURP) with a three-way urinary catheter and continuous bladder irrigation (CBI) running. Which nursing interventions are appropriate? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=374201&lang=en  
> language: en  
> subject: Basic Care and Comfort  
> category: BCC

## Question

A patient is post-op day 0 from a transurethral resection of the prostate (TURP) with a three-way urinary catheter and continuous bladder irrigation (CBI) running. Which nursing interventions are appropriate? Select all that apply.

1

Assess for bladder distention, sudden severe spasms, or absent drainage — these may indicate clot obstruction requiring manual irrigation per protocol.

2

Calculate true urine output by SUBTRACTING the irrigation volume infused from the total drainage volume.

3

Irrigate the catheter manually with 50 mL of sterile saline every 2 hours as a routine to maintain patency and prevent clot formation.

4

Anticipate scheduled antimuscarinic agents (such as oxybutynin) or belladonna-and-opium suppositories for severe bladder spasms when ordered.

5

Titrate the CBI rate to keep the urine output light pink to clear; increase the rate if output becomes darker red or contains clots.

## Explanation

CBI post-TURP nursing care: titrate rate to keep output light pink to clear (faster if output darkens or clots form), calculate true UOP by subtracting irrigation in from total drainage out, assess for clot obstruction signs (distention, spasms, no drainage) and manage per protocol with manual irrigation, anticipate antimuscarinic or B&O suppositories for spasms. Choice 3 is incorrect — routine manual irrigation every 2 hours is not indicated; manual irrigation should only be performed when signs of clot obstruction are present, as unnecessary irrigation increases the risk of infection and urethral trauma.

## In-depth explanation

The two most-tested TURP/CBI principles: (1) urine SUBTRACTION math is on every NCLEX cycle — total drainage minus irrigation in = true urine output; (2) clot obstruction (sudden distention, severe spasm, no drainage) requires manual irrigation per protocol, not waiting. Bright red output or escalating clots = call urology STAT for possible bleeding from the prostatic bed.

## Clinical scenario

**Post-op day 0 TURP, three-way urinary catheter, CBI running with normal saline**. The output is currently pink-tinged and free of clots. The patient is alert and reports mild bladder pressure but no severe pain.

## Key concepts

- **Continuous bladder irrigation (CBI)** — Continuous saline irrigation through a three-way catheter post-TURP to flush clots and prevent obstruction.
- **True urine output calculation** — Total drainage volume minus irrigation volume infused = true urine output.
- **Clot obstruction signs** — Bladder distention, sudden severe spasms, absent drainage; perform manual irrigation per protocol and notify provider.

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