The nurse is monitoring hourly urine output from an indwelling catheter for a patient experiencing hypovolemic shock. What should the nurse do if the patient's urine output drops to 15 mL for one hour of monitoring?
a. Document the finding.
b. Flush the urinary catheter
c. Clamp the catheter for 30 minutes.
d. Immediately report the drop in urine output.
ANS: D
The kidneys can tolerate reduced blood flow for about 1 hour before sustaining permanent damage. Cells in the kidneys die when there is a lack of oxygen and nutrients. If there is widespread damage to the kidneys, complete renal failure is likely. A. The nurse needs to do more than document the findings. B. The urinary catheter does not need to be flushed. C. Clamping the catheter for 30 minutes is not going to improve the patient's urine output.
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