A patient receiving continuous bladder irrigation reports severe suprapubic pressure, and no drainage has entered the collection bag for 30 minutes. What should the nurse do first?
Correct answer: A. Check the tubing for kinks or dependent loops
- A. Check the tubing for kinks or dependent loops
- B. Increase the irrigation rate to its maximum setting
- C. Remove the catheter and insert a new one
- D. Administer an opioid and reassess in one hour
Explanation
Suprapubic pressure with absent drainage suggests obstruction of the irrigation system. The nurse first checks the tubing, connections, and bag position, then follows the prescribed procedure for restoring patency. Increasing the rate without checking the system can worsen bladder distension.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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