The charge nurse is making rounds and should immediately intervene when making which observation?

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11ecbb05_ca80_c575_b433_fbeac951ce8d_MD0009_00 The flow of urine is dependent on gravity. In order to maintain gravity flow, the drainage bag should be hung below the level of the bladder. Impaired urine flow can lead to urinary retention and distension of the bladder. (Option A) Catheters placed in the kidney pelvis are irrigated using gentle pressure and small amounts of sterile saline solution (≤5 mL at one time) to avoid damaging renal tissues. (Option C) Securing an indwelling urinary catheter by taping it to a client's leg is acceptable to maintain gravity flow and prevent kinks and occlusions. Also, Velcro securement devices may be available at certain facilities. (Option D) Fluid intake of 3,000 mL per day should be encouraged in clients after surgery involving the urinary system. Increased fluid intake ensures the maintenance of a high urinary output, reducing the risk for infection. Dilute urine is less irritating to the skin surrounding the stoma site. Electrolyte reabsorption from reservoirs may increase risk for calculi. However, high fluid intake and urine output reduce this risk. Educational objective: The flow of urine is dependent on gravity. The drainage bag should be hung below the level of the bladder to maintain gravity flow.

The Charge Nurse Is Making Rounds and Should immediately Intervene