A postsurgical client's urinary output via the Foley catheter is 30 mL in 3 hours. What is the nurse's first action?
a. Increase the IV infusion rate.
b. Assess the client's skin turgor.
c. Weigh the client.
d. Check the patency of the catheter.
D
The nurse should check to ensure that the client's catheter tubing is patent. If the catheter is pa-tent, the nurse should increase the IV flow rate if there are orders to do so, or should call the surgeon to report the information and request more fluids. Assessing the skin turgor would give information on hydration status, but this would not be the first intervention. Weighing the client probably would not give relevant information related to this client because the concern has arisen in the last 3 hours.
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