The nurse understands that examples of sensible fluid loss in a client are: (SELECT ALL THAT APPLY)

A. Asking the client to bear down as if urinating: This action is not appropriate in this situation because the lack of urine output may not necessarily be due to the client's inability to void. Checking for other potential issues, such as kinks in the tubing, is more appropriate as a first step.

B. Check for kinks in the tubing: This is the most appropriate first action. Kinks in the tubing can obstruct urine flow from the bladder to the drainage bag, leading to decreased or no urine output. By checking for kinks, the nurse can quickly identify and correct any obstructions, potentially resolving the issue without further intervention.

C. Increasing fluid intake: While maintaining adequate hydration is important for overall urinary function, it is not the most immediate action needed when there is no urine output in the catheter bag. Addressing potential mechanical issues, such as kinks in the tubing, takes precedence.

D. Inserting a new indwelling urinary catheter: Inserting a new catheter should not be the first action taken without investigating other potential causes for the lack of urine output. It is important to troubleshoot and address possible issues with the current catheter and drainage system before considering catheter replacement.

A. Discuss the situation with another colleague and formulate a plan: While discussing the situation with a colleague and formulating a plan may seem like a reasonable approach, it may not address the immediate concern of potential impairment. Delays in reporting could result in the impaired nurse continuing to work, posing a risk to patient safety. Therefore, this option is not the most appropriate action in this scenario.

B. Ask the impaired nurse to go home, or the incident will be reported to the manager: While it may be necessary for the impaired nurse to leave work if they are unfit to practice safely, this action should be taken after informing the appropriate authority figures. Additionally, threatening to report the incident to the manager without following through on informing them immediately may not effectively address the issue. Therefore, this option is not the most appropriate action in this scenario.

C. Immediately inform the charge nurse or the nurse manager of the nurse's breath odor: This is the most appropriate action in this scenario. If a nurse suspects that a colleague may be impaired, it is crucial to report it immediately to the charge nurse or nurse manager. Prompt reporting allows for timely intervention to ensure patient safety and address the nurse's well-being. The charge nurse or nurse manager can then take appropriate steps, such as conducting an assessment, intervening as necessary, and following institutional policies and procedures for addressing impairment.

D. Research the state's peer assistance program and discuss the program with the nurse: While peer assistance programs can be valuable resources for nurses experiencing impairment, they are not the most immediate or appropriate action in this scenario. Addressing the issue of potential impairment requires timely reporting to the charge nurse or nurse manager to ensure patient safety and provide support for the impaired nurse. Therefore, this option is not the most appropriate action in this scenario.