Irrational question rationale

[EmpathyInAction]

Help Please - I got an NCLEX question wrong while studying but the rationale isn't... rational to me. Mind offering some insight?

Q: After a retropubic prostatectomy for treatment of benign prostatic hyperplasia, a client enters the post-anesthesia care unit with a three way Foley catheter that has a continuous irrigation of normal saline infusing. On the initial assessment of the urine in the Foley catheter bag, the nurse notes that the drainage is dark red. Which action should the nurse take?

1) Chart the drainage color as the only action.

2) Increase the flow rate of the irrigation solution until the urine is a light pink.

3) Notify the primary healthcare provider of the dark red drainage from the Foley.

4) Pull traction on the Foley tubing and tape the Foley tubing to the clients leg.

The answer key says #2 is correct. Now I take issue with this because I was always taught that you are not allowed to change the flow rate on anything and therefore test answers like this were always wrong because it was considered "changing the doctors orders".... meaning #3 would be correct so he could change the ordered flow rate. So someone please help explain to me why this is the correct answer.

[Graduatenurse14]

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

[dbrenda1510]

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??

[THELIVINGWORST, ASN, RN]

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.

[TheCommuter, BSN, RN]

3) Notify the primary healthcare provider of the dark red drainage from the Foley.

Why would you notify the primary care provider of the dark red drainage from the Foley? Remember that this patient is in the PACU (read: post anesthesia recovery unit), which means he just came from the operating room.

The patient just got operated on. Now that we know this information, the dark red drainage from the Foley would be a normal finding. Remember that the patient was just cut open. Why call the doctor over a normal finding?

We want that urine to be lighter, so increasing the irrigation rate makes sense. PACU nurses work under predetermined protocols and standing orders, so when taking NCLEX, assume you have an order to carry out whatever interventions are listed.

[JustBeachyNurse, LPN]

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.

[Pangea Reunited, ASN, RN]

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.

[dandan4o9]

great topic and responses. I learned something new today.

[EmpathyInAction]

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!

[ArrowRN, BSN, RN]

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.

[JustBeachyNurse, LPN]

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