The nurse is caring for a patient who had prostate surgery the previous day. The patient has had significantly decreased urine output over the last shift despite ample oral and IV fluid intake.
The patient's urine from the indwelling catheter is cherry red with occasional small clots. What is the appropriate action of the nurse?
a.
Remove the urinary catheter and replace it with a new one
b.
Gently irrigate the catheter using warmed sterile normal saline
c.
Send a sample of the patient's urine to the laboratory for analysis
d.
Call the physician and obtain an order for kidney and bladder ultrasound
Question 2
The nurse is caring for a patient with benign prostatic hypertrophy who states that he feels a constant urge to urinate but cannot pass more than 30 to 60 mL of urine into the toilet at a time.
The nurse performs a bladder scan and finds that there are 1100 mL of urine in the patient's bladder. What is the priority nursing diagnosis for this patient?
a.
Alteration in comfort r/t continual urge to urinate
b.
Overflow urinary incontinence r/t over-distention of the bladder
c.
Urinary retention r/t obstruction of urinary bladder outlet
d.
Toileting self-care deficit r/t inability to pass urine into the toilet
Patient education
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