A nurse is continuously irrigating the bladder for the client who has had a prostatectomy. The irrigation infusion rate is 1000 mL/hr. The client's urine output for the past hour is 200 mL. What is the nurse's best first action?
A. Notify the physician.
B. Stop the irrigation flow.
C. Document the finding as the only action.
D. Irrigate the catheter with a large piston syringe.
B
The catheter output should be at least the volume of irrigation input plus the client's actual urine. A severe decrease in output indicates obstruction in the drainage system. The first action is to stop the irrigation flow to prevent severe bladder distention. The next action is to check the ex-ternal system for kinks or obstruction. If no output occurs, the catheter is irrigated with 30 to 50 mL of normal saline using a large piston syringe. If the obstruction is not resolved, the physician must be notified.
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