A client has a heminephrectomy and returns from the postanesthesia care unit with a nephrostomy tube and an indwelling urinary catheter. The client’s urinary output is 50 mL/hr. What is the nurse’s next action?
ExplanationA. An output of 50 mL/hr is adequate. When output drops to less than 30 mL/hr, it may indicate renal failure and the health care provider should be notified.
B. Irrigating the nephrostomy is unnecessary and requires a health care provider’s order.
C. Encouraging oral fluids is contraindicated. The client probably will still be under the influence of anesthesia and have no gag reflex.
D. The health care provider should be notified when the hourly output drops to less than 30 mL/hr