Irrational question rationale

I've done hundreds of Kaplan and PDA questions so I am very used to irrational rationales. They are crazy!!!

Since it is immediate post operation perhaps the greatest worry is hemorrhage. If the normal saline solution increase and output urine is pink the threat of hemorrhage is greatly lessened. Anyone else have another view??

It's supposed to be that color. The purpose of irrigating a bladder is to prevent the clotting of blood. You can change the rate depending on the color of the urine. If it's dark you increase the rate, if it's pale yellow for a while with no clots then you can let the doc know so he can decide if he wants to D/C it.

Changing the flow rate on CBI is not the same as changing the flow on an IV drug or fluid. Usually a CBI is continuous infusion of 0.9% saline to achieve pink tinged drainage.

If dark red there is insufficient irrigation and the patient is high risk for clots.

This is one of the few scenarios where fluid flow is adjusted by patient response/nursing judgement.

Answer 2 makes perfect sense, to me ...but I can see why someone without experience would be confused. I've never received a CBI patient without some type of adjustment order (irrigate to clear, hand held irrigation PRN etc.), but the question doesn't mention any orders or instructions given. That's pretty atypical.

great topic and responses. I learned something new today.

See the rationale for titration makes perfect sense to me and therefore would have made option #2 correct for me, but the lack of orders threw me, which is why I felt 3 was correct.

NCLEX is frustrating cuz in school they say "don't read into the question, don't assume there are orders that aren't listed, don't assume things" but then you have to reprogram your brain to do exactly some of those things for the NCLEX.

Thanks for the responses!

my rationale would be to eliminate Eliminate 4 first cause that would compromise patient safety. 3 cause its notifying the provider of an expected finding and also cause the questions asks for a NURSING action...in "NCLEX world" only notify provider of unexpected adverse findings. Good options would be 1 or 2. Just charting is equivalent to the nurse saying "I am going to do nothing" which is inappropriate. 2 it is because flushing also reduces chance of clotting.

my rationale would be to eliminate Eliminate 4 first cause that would compromise patient safety. 3 cause its notifying the provider of an expected finding and also cause the questions asks for a NURSING action...in "NCLEX world" only notify provider of unexpected adverse findings. Good options would be 1 or 2. Just charting is equivalent to the nurse saying "I am going to do nothing" which is inappropriate. 2 it is because flushing also reduces chance of clotting.

Nice logic! Good articulation of your thought process