The nurse assesses that a patient receiving epidural morphine has not voided for over 10 hours. What action should the nurse take initially?
a. Monitor for withdrawal symptoms.
b. Place an indwelling urinary catheter.
c. Ask if the patient feels the need to void.
d. Document this allergic reaction in the patient's chart.
ANS: C
Urinary retention is a common side effect of epidural opioids. Assess whether the patient feels the need to void. Since urinary retention is a possible side effect, there is no reason for concern of withdrawal symptoms. Placing an indwelling catheter requires an order from the health care provider. Usually an in and out catheter is performed to empty the bladder if the patient is unable to void because of the risk of infection with an indwelling catheter. Urinary retention does not indicate that this reaction is an allergic reaction.
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