A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr.

Which of the following interventions should the nurse anticipate?

Administer a fluid bolus

Initiate continuous bladder irrigation

Obtain a urine specimen for culture and sensitivity

Clamp the catheter tubing for 30 min

Answer and Explanation

The Correct Answer is A

The correct answer is choice A, administer a fluid bolus.

Choice A rationale:

Administering a fluid bolus is appropriate when a client’s urine output is low, which in this case is less than the minimum expected output of 30 mL/hr. The dark yellow color of the urine also suggests dehydration or concentrated urine, which can be addressed with increased fluid intake.

Choice B rationale:

Initiating continuous bladder irrigation is typically done to clear the urinary tract of blood clots or debris following urologic surgery, not for low urine output or dark urine. Therefore, this intervention is not indicated based on the given scenario.

Choice C rationale:

Obtaining a urine specimen for culture and sensitivity is an action taken when there is a suspicion of a urinary tract infection. The scenario does not provide evidence of infection, such as fever or cloudy urine with a strong odor, so this would not be the first intervention to anticipate.

Choice D rationale:

Clamping the catheter tubing is done in preparation for catheter removal or to assess if the client can void without the catheter. It is not an appropriate intervention for low urine output or dark urine and could potentially cause bladder distention or discomfort.

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Correct Answer is A

Explanation

A. “It’s okay to be nervous before this treatment.”. B. “Most people who have this procedure feel better following the treatment.”. C. “Your doctor wouldn’t have ordered this treatment unless it was necessary.”. D. “You don’t have to go through with the treatment

Correct Answer is D

No explanation

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A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr.

Which of the following interventions should the nurse anticipate?