A 32-year-old woman who has a fractured T-7 following an automobile accident develops urinary retention. The physician orders intermittent catheterizations every 6 hours, and the nurse obtains between 600 and 830 mL of urine each time. Select the most appropriate nursing action for this client.
A)Notify the physician and obtain an order for a Foley catheter.
B)Restrict the client's fluid intake to 500 mL per shift.
C)Obtain an order to catheterize the client every 3 to 4 hours.
D)Continue catheterizing the client per the physician's order.

Question

Quizplus · Accepted Answer

Obtaining an order to catheterize the client more frequently (every 3 to 4 hours) is appropriate because the volumes of urine obtained indicate that the bladder is being allowed to fill too much, which can lead to bladder distension and further complications. The current schedule of every 6 hours is not sufficient to prevent these risks.

A 32-Year-Old Woman Who Has a Fractured T-7 Following an Automobile