The nurse notes that the client's indwelling urinary catheter bag has had no urine output since being emptied 1 hour ago. What should the nurse's first action be?

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.

A. Daily weights, vital signs, and fluid intake and output: These are essential nursing assessments and interventions that can be implemented without a physician's order to monitor the client's fluid volume deficit and hypovolemia. Daily weights help assess changes in fluid status, vital signs provide information on the client's hemodynamic stability, and monitoring fluid intake and output helps track fluid balance.

B. Monitoring temperature, fluid intake and output, and administering IV fluids: While monitoring temperature and fluid intake and output are important aspects of nursing care, administering IV fluids typically requires a physician's order, especially in the context of hypovolemia. The nurse should collaborate with the healthcare team to determine the need for IV fluid therapy.

C. Auscultation of lung sounds, monitoring urine color, and placing an indwelling urinary catheter in the client: Auscultation of lung sounds and monitoring urine color are relevant assessments for fluid volume status, but placing an indwelling urinary catheter typically requires a physician's order unless there is a specific nursing protocol in place allowing nurses to insert catheters under certain circumstances.

D. Daily weights, diuretics, and waist measurement: While daily weights are appropriate for assessing fluid status, administering diuretics should be based on a physician's order and assessment findings. Waist measurement is not typically used to assess fluid volume deficit and hypovolemia.