A patient with progressive shock is diaphoretic and confused. The most recent blood pressure measurement was 82/40 mm Hg and a urinary catheter output was 10 mL for 1 hour. Intravenous (IV) fluids are infusing at 150 mL/hr
Which action should the nurse take related to the urine output?
a. Encourage oral fluids.
b. Irrigate urinary catheter.
c. Increase IV fluid infusion rate.
d. Check urinary catheter for kinking.
ANS: D
Collecting data is the first step in critically thinking about a situation. In this case, the urine output is lower than normal, which could be due to several reasons. The initial action of the nurse should be to inspect the urinary catheter system for proper functioning. If the catheter system is inhibiting urine output, then that issue must be addressed to correct the situation. Other interventions will not help if the system is the cause. B. Catheter irrigation is invasive and breaks the sterile system. A. Oral fluids will not help if the system is kinked; also the patient is confused and so may not be able to take oral fluids safely, and an IV is infusing to hydrate the patient. C. An order is needed to increase the IV rate.
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