GMCH Chandigarh - 2019
Nursing Foundation
Medium
Which of the following is a primary nursing intervention necessary for a patient complain of pain abdomen with Foley catheter urine output nill ?
Appeared in: GMCH Chandigarh - 2019
Explanation
- The patient's symptoms of abdominal pain with no urine output from the Foley catheter are classic signs of a blockage causing urinary retention.
- The primary and most immediate nursing action is to assess for and correct common mechanical obstructions.
- Checking the tubing for kinks and ensuring the collection bag is positioned below the bladder for gravity drainage are the first steps in troubleshooting.
- This simple intervention can often resolve the issue immediately, relieve the patient's pain, and prevent complications.
Why Other Options Were Wrong
- Option A: Positioning the drainage bag level with the bladder prevents urine from draining via gravity and can cause urine to flow back into the bladder, increasing infection risk.
- Option B: Routine irrigation is not recommended as it breaks the closed sterile system, increasing infection risk. It also requires a specific physician's order.
- Option D: Informing the doctor is a secondary action. The nurse's primary responsibility is to first assess the situation and perform basic troubleshooting interventions that are within their scope of practice.
Related Visual
Clinical Relevance
- Nursing practice connection: Use the key finding related to Foley Catheter Management and Troubleshooting to guide bedside assessment, documentation, and the next nursing action.
- Promptly identifying and resolving a catheter obstruction is a critical patient safety measure to prevent bladder distention, pain, and potential bladder damage.
- Maintaining a closed drainage system and proper bag placement are key principles in preventing Catheter-Associated Urinary Tract Infections (CAUTIs), a common and serious healthcare-associated infection.
- What if? - If the nurse checks the tubing, finds no kinks, ensures the bag is below the bladder, and there is still no urine output, the next step would be to gently palpate the suprapubic area for bladder distention and then notify the healthcare provider promptly, as the obstruction may be internal (e.g., a clot).
How to Approach the Question
- First, analyze the clinical scenario: a patient with a Foley catheter has abdominal pain and no urine output. This combination points directly to a blockage and urinary retention.
- Next, apply the nursing process. The first step is always assessment and a simple, immediate intervention.
- Evaluate the options based on this principle. Which option represents the most immediate and appropriate assessment/intervention?
- Option C (checking for kinks and bag position) is a direct assessment and intervention for the most common cause of the problem.
- Rule out the other options: Option A is harmful, Option B is an advanced procedure requiring an order, and Option D is a later step in the escalation process.
- Therefore, the best initial action is to troubleshoot the equipment, making Option C the correct answer.
Concept Tested & Keywords
- Concept Tested: Foley Catheter Management and Troubleshooting
- Stem keywords: pain abdomen, Foley catheter, urine output nill
- Lead-in keywords: primary nursing intervention
- Clinical cues: The combination of abdominal pain and no urine output from a catheter strongly indicates a blockage and urinary retention.
Question ID
Q9pIOvyzsnEOVM5nLjOvSc
Reference Book
E6 Nursing Fundamentals Potter Perry 12e Part 5 p. 254-255
E6 Nursing Fundamentals Potter Perry 12e Part 6 p. 18-20
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