The nurse observes a distended bladder and no change in urine output in a patient with an indwelling urinary catheter and drainage system. What should the nurse do first?
1. assess the catheter tubing for kinks and position it so drainage is maintained by gravity
2. notify the physician
3. flush the catheter with sterile saline using a large syringe
4. change the catheter
Correct Answer: 1
The nurse should assess and maintain the patency and integrity of all catheter systems. A kinked catheter may damage the urinary system. Notifying the physician is not an immediate intervention. Flushing or changing a catheter increases the risk of infection.
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