A nurse is caring for a client who is receiving a transfusion of packed red blood cells and develops itching and hives. What should be the nurse’s first response?

Choice B rationale:

Checking the patency of the tubing is the first and most crucial step in addressing the lack of urinary output in this patient. Here's a detailed explanation of why this is the priority action:

Addresses the Most Likely Cause: Obstruction of the urinary catheter tubing is the most common and easily reversible cause of sudden cessation of urinary output in a patient with a continuous bladder irrigation system.

Prevents Complications: A blocked catheter can lead to a number of serious complications, including: Bladder distention, which can cause pain, discomfort, and potential bladder damage.

Urinary retention, which can increase the risk of urinary tract infections (UTIs) and kidney damage. Hematuria, or blood in the urine, due to clot formation in the bladder or catheter.

Non-Invasive Intervention: Checking the tubing is a simple, non-invasive procedure that can quickly identify and resolve the issue without requiring further interventions or delays in care.

Prioritizes Patient Safety: It's essential to promptly address any potential urinary obstruction to prevent the aforementioned complications and ensure patient safety.

Rationale for Other Choices:

Choice A: Administering a prescribed analgesic:

While pain management is important, it does not directly address the lack of urinary output. Pain medication would be appropriate if pain were assessed to be the cause of the decreased output, but it's not the first priority in this situation.

Choice C: Notifying the provider:

Although the provider should be informed of the situation, checking the tubing for patency is a necessary first step to gather more information and potentially resolve the issue quickly without requiring further intervention.

Choice D: Offering oral fluids:

Increasing fluid intake might be helpful in some cases of decreased urinary output, but it's not the priority action in a patient with a continuous bladder irrigation system and a potential catheter obstruction.

Choice A rationale:

While explaining the importance and rationale of the new policy can be helpful, it may not address the underlying reasons for the nurse's resistance.

If the nurse does not understand or agree with the rationale, they may still be resistant to change.

Additionally, simply providing information may not create an open and trusting environment where the nurse feels comfortable expressing their concerns.

Choice B rationale:

Encouraging the nurse to verbalize their concerns allows the nurse manager to understand the specific reasons for the resistance.

This can help to identify any misconceptions or concerns that can be addressed directly.

It also gives the nurse an opportunity to feel heard and understood, which can help to build trust and rapport. When nurses feel that their concerns are being taken seriously, they are more likely to be open to change.

Choice C rationale:

Threatening disciplinary action is likely to create resentment and further resistance. It may also damage the relationship between the nurse manager and the nurse.

This approach should only be used as a last resort, after other attempts to address the resistance have failed.

Choice D rationale:

Ignoring the resistance is not an effective strategy.

It is likely to lead to continued noncompliance with the new policy,

It may also send the message that the nurse manager does not care about the nurse's concerns.

Peer pressure can sometimes be helpful in facilitating change, but it should not be relied upon as the sole strategy.