While being catheterized for urinary retention, a patient becomes diaphoretic and pale. What should the nurse do to help this patient?
1. The nurse should clamp the catheter after draining 500 mL of urine.
2. No action is needed, as this situation is transient.
3. The nurse should remove the urinary catheter.
4. The nurse should provide the patient with fluids.
Correct Answer: 1
Some patients may experience a vasovagal response and become pale, sweaty and hypotensive if the bladder is rapidly drained. The nurse should be aware that it is a possible response in some patients and be able to recognize it and take the appropriate action. Draining 500 mL increments and clamping the catheter for 5 to 10 minutes between increments may prevent this response. Removing the urinary catheter or replacing fluids will not address the symptoms.
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