A nurse is caring for a client receiving mechanical ventilation via an endotracheal (ET) tube. The high-pressure alarm is beeping, and the client is experiencing respiratory distress. The nurse is unable to determine the cause of the alarm. Which of the following actions should the nurse take?

• Urinary output is an important indicator of fluid balance and kidney function. After delivery, a woman may experience increased urinary output due to the loss of excess fluid that was retained during pregnancy and the diuretic effect of oxytocin, which is released during breastfeeding. This is a normal and expected finding in the postpartum period.
• However, increased urinary output may also be a sign of urinary retention, which is the inability to empty the bladder completely. Urinary retention can occur due to trauma to the bladder or urethra during delivery, swelling or hematoma of the perineum, epidural anesthesia, or decreased bladder sensation.Urinary retention can lead to complications such as infection, bladder distension, or postpartum hemorrhage.
• Therefore, when a woman who delivered a normal newborn 24 hours ago reports that she seems to be urinating every hour or so, the practical nurse (PN) should measure the next voiding, then palpate the client's bladder. This will help to assess the amount and quality of urine and the presence or absence of bladder distension. A normal urine output is about 30 ml per hour, and a normal bladder should feel soft and empty after voiding. If the urine output is low or high, or if the bladder feels firm or full after voiding, the PN should report these findings to the primary healthcare provider for further evaluation and intervention.

Therefore, option B is the correct answer, while options A, C, and D are incorrect.

Option A is incorrect because catheterizing the client for residual urine volume is an invasive procedure that should only be done if indicated by the primary healthcare provider.

Option C is incorrect because evaluating for normal involution and massaging the fundus are related to uterine function, not urinary function.

Option D is incorrect because obtaining a specimen for urine culture and sensitivity is not necessary unless there are signs of infection, such as fever, dysuria, or foul-smelling urine.

A. Correct. Designating a health care surrogate is one of the components of an advance directive, which allows the client to appoint someone who can make medical decisions on their behalf if they are unable to do so themselves.

B. Incorrect. Age is not a factor that determines the need for an advance directive, as anyone can become incapacitated at any time due to illness or injury.

C. Incorrect. A lawyer's help is not necessary to draw up an advance directive, as there are standardized forms available that can be filled out by the client and witnessed by two adults.

D. Incorrect. The family cannot alter or override the advance directives of the client unless they have been designated as their health care surrogate or have obtained a court order to do so.