The nurse is caring for a patient who is receiving diphenhydramine. The nurse notes that the patient has not voided for 12 hours. What action will the nurse take?
a. Encourage the patient to drink more fluids.
b. Evaluate the bladder to check for distension.
c. Request an order for an intravenous fluid bolus.
d. Request an order for urinary catheterization.
ANS: B
Diphenhydramine has anticholinergic effects, including urinary retention. The nurse should assess for bladder distension to determine if this is the case. Encouraging the patient to drink more fluids or giving intravenous fluids may be necessary if the patient has oliguria secondary to dehydration. Urinary catheterization is not indicated until urinary retention has been identified.
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