A patient's Foley catheter was removed before 24 hours. Now his/her urine output is less than the expected volume. What will the nurse do first?

Appeared in: JIPMER Nursing Officer - 2020

Explanation

The nursing process (ADPIE: Assessment, Diagnosis, Planning, Implementation, Evaluation) dictates that assessment is always the first step.
Checking for bladder distension is the primary assessment to determine if the low urine output is due to urinary retention (the bladder is full but cannot empty) or a problem with urine production (the bladder is empty).
This initial assessment is critical because the interventions for retention (e.g., bladder scan, potential catheterization) are completely different from interventions for poor urine production (e.g., hydration, renal function tests).
Acting without assessing can lead to incorrect and potentially harmful interventions.

Option B: Informing the doctor is an important step, but it should occur after the nurse has gathered essential assessment data. The doctor's first question will likely be, 'Is the bladder distended?'.
Option C: Ambulation is a non-pharmacological intervention to encourage voiding. It is an implementation step, which comes after assessment in the nursing process.
Option D: Administering a diuretic like Lasix is dangerous if the patient has urinary retention. It increases urine production, which would further distend an already full bladder, causing severe pain and potentially leading to bladder rupture.

Clinical Relevance

Nursing practice connection: Safe nursing care depends on performing Post-catheter removal care and management of urinary retention in the correct sequence, documenting the action clearly, and monitoring for the expected response.
This scenario reinforces the foundational nursing principle: 'Assess before you act.' Intervening without a proper assessment can lead to patient harm.
Post-operative and post-catheterization urinary retention is a common complication. Nurses must be vigilant in monitoring urine output and assessing for bladder fullness.
Patient Safety: Administering a diuretic to a patient in urinary retention is a serious medication error with potentially severe consequences, including bladder rupture.

How to Approach the Question

First, identify the question type. This is a 'priority' or 'first action' question, indicated by the word 'first'.
Recall the steps of the nursing process: Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE).
Remember that Assessment is always the initial step in any clinical scenario.
Analyze the four options to determine which one represents an assessment action.
Option A ('Check bladder for distension') is a direct assessment. Options B, C, and D are interventions or reporting actions.
Therefore, the assessment action is the correct first step for the nurse to take.

Concept Tested & Keywords

Concept Tested: Post-catheter removal care and management of urinary retention.
Stem keywords: Foley catheter, removed, urine output, less than expected
Lead-in keywords: first
Clinical cues: The recent removal of a Foley catheter is a key cue, as it is a common precursor to temporary urinary retention.

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E6 Nursing Fundamentals Potter Perry 12e Part 6 p. 17-19

Practise the full JIPMER Nursing Officer - 2020

Attempt every question from this paper in a timed mock, then review the full solution for each one.