The nurse determines that the client's urinary output is 150 ml for 8 hours from the suprapubic catheter. Which does the nurse implement as a follow-up nursing intervention?
1. Encourage coughing and deep breathing.
2. Clamp the urinary catheter for 30 minutes.
3. Collaborate with the provider for a diuretic.
4. Assess client's intake and catheter patency.
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4. Before concluding that the client's urinary output is deficient, the nurse completes the assessment to eliminate inadequate intake and catheter obstruction as potential causes of the low urine output. The nurse expected at least 240 ml of urine in 8 hours.
1. Coughing and deep breathing is an ineffective response for low urine output be-cause the potential causes include fluid volume deficiency, renal insufficiency, heart failure, and catheter obstruction. The nurse eliminates catheter obstruction as a po-tential cause as soon as possible because, compared with the other potential causes, it is more easily resolved.
2. Clamping the catheter is the last nursing intervention the nurse wants to implement because it is wholly counterproductive.
3. The nurse needs to complete the urinary assessment before determining that a di-uretic is suitable therapy for the client; if a diuretic were proper, the client should ex-hibit other clinical indicators of fluid volume overload such as crackles, edema, and jugular venous distention.
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