The nurse is performing hourly assessments on a client in the compensation stage of shock. In documenting the hourly urine output of 40 mL from the Foley catheter, which nursing action is most appropriate?
A) Reposition the client and make sure there are no kinks in the catheter tubing.
B) Notify the physician of the hourly output and encourage physician assessment.
C) Record 40 mL as the hourly output.
D) Notify the family of the urine output.
C
Feedback:
Urine output above 35 mL/hour or 500 mL/day indicates adequate kidney perfusion. The hourly output would be documented in the client record. There is no need to reposition the client or look for a kink because adequate amounts of urine is collecting in the tube. There is no need to notify the physician or family.
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